Every finding on record at Life Care Center of La Center

Based on interview, record review, and policy review, it was determined that the facility failed to ensure the resident or the resident's representative received a written notice of the facility's bed hold policy when the residents were hospitalized for [REDACTED]. Resident #11 was transferred to the hospital on [DATE] and Resident #51 was transferred to the hospital on [DATE]. There was no evidence that Resident #11's or Resident #51's responsible party was given written notification of the bed hold and the reserve bed payment policy upon transfer to the hospital. The findings include: Review of the facility's policy entitled Resident Admission Agreement, dated (YEAR), revealed that at the time a resident is to leave the facility for a temporary stay in a hospital or for therapeutic leave, the resident or the resident's legal representative will be given a written copy of the Bed Hold Policy and may elect to hold open the room and bed until the resident's return to the facility. Further review of the Admission Agreement revealed that at the time of transfer, the resident or the resident's legal representative will indicate in writing whether they desire or decline the bed hold. Further review of the Resident Admission Agreement revealed that the resident will be notified of the rate at the time of temporary discharge. 1. Observation on 12/16/19 at 11:36 AM revealed Resident #11 was sitting in a wheelchair in his/her room. Further observation revealed the resident was alert and pleasant, but confused. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of nine (9) indicating the resident had moderately impaired cognition. Review of the nursing progress notes dated 09/26/19 at 10:31 AM revealed Resident #11 was noted to have pneumonia. The note stated that the resident had received a one-time antibiotic injection and was started on an oral antibiotic on 9/25/19. Review of the nursing progress notes dated 09/26/19 at 11:05 PM for Resident #11 revealed the aide notified the nurse that the resident's blood pressure was low. Further review of the note revealed the nurse assessed the resident and the resident's blood pressure was 70/42, pulse was 144, and respirations were 22 with an oxygen saturation of 91 percent and temperature of 101.2. Further review revealed the responsible party and the physician were notified of the resident's condition. According to the progress notes, the physician ordered the resident to be sent to the emergency room . Further review of the progress note revealed no documentation that the resident or the resident's responsible party received a written notice of the bed hold that included if the resident desired for the bed to be held or desired to decline, and included the rate for the cost of the bed hold. Interview with the Business Office Manager on 12/18/19 at 12:39 PM revealed that the facility is not at capacity and the staff seldom ask a resident regarding bed hold. According to the interview, the facility holds all beds for the residents. Further interview revealed no phone calls or notifications are made to the responsible party related to the bed hold or the cost of the bed charges. Interview with the Director of Nursing (DON) on 12/18/19 at 12:20 PM revealed the staff should be notifying the family of the status of the bed hold; however, the staff does not do the bed hold notifications due to being a small facility and not having many admissions. Further interview revealed the facility holds the beds for all residents. According to the interview, the DON was unable to find any information that Resident #11's responsible party was notified of the bed hold prior to the transfer to the hospital. Interview with the Administrator on 12/18/19 at 12:28 PM revealed the Administrator expected the staff to provide a copy of the bed hold policy to the resident at the time of transfer. According to the interview, the business office manager would call the family if they were going to request a financial bed hold. Further interview revealed there was no evidence that Resident #11's responsible party was notified of the bed hold and the cost of the reserve bed payment. According to the interview, the resident was not charged for holding the bed during the resident's hospital stay. 2. Review of the medical record for Resident #51 revealed the facility admitted the resident on 10/23/19 with [DIAGNOSES REDACTED]. Review of the nurse's notes for Resident #51 revealed an entry dated 10/25/19 at 11:33 AM stating the resident had been sent to the acute care hospital for decreased level of consciousness and an increased blood glucose level. The nurse's note also revealed that a copy of the bed hold policy was sent with the resident. However, there was no indication of whether the resident or the responsible party had elected to choose bed hold. In addition, review of a copy of the facility's bed hold policy revealed there was no amount listed as to what would be expected as payment for bed hold after the days were exhausted. Interview conducted with Registered Nurse (RN) #1 on 12/18/19 at 12:17 PM, revealed she had transferred Resident #51 to the hospital on [DATE]. The RN stated she had been directed to just send a copy of the bed hold policy with the resident to the hospital. The RN further stated she generally did not tell residents or responsible parties about bed hold. Interview conducted with the Director of Nursing (DON) on12/18/19 at 12:20 PM, revealed the facility should notify the family of the status of the bed. However, we don't here as much because we are so small and hold everybody's bed. Interview conducted with the Administrator on 12/18/19 at 12:28 PM, revealed the facility was currently just providing the bed hold policy and not asking the resident or family if they would like for the facility to hold the resident's bed at the time of transfer. The Administrator stated if a resident used all their bed hold days and the bed was needed for another resident the responsible party would be contacted to see if they wanted to pay for bed hold and the amount to be charged would be relayed at that time. Per the Adminstrator, no calls were made to Resident #11, Resident #51, or their responsible parties regarding bed hold. The Administrator stated residents were never charged bed hold here unless the facility needed the bed. The Administrator stated it had been a long time since the facility called a resident or resident's representative to see if they wanted to request a bed hold. The Administrator stated she did not regard it as a problem since the residents were not going to lose their beds.

Based on observation, interview, record review, and facility policy review it was determined that the facility failed to ensure an ongoing program of activities was developed to meet the needs of one (1) of eighteen (18) sampled residents (Resident #1). Interview conducted with Resident #1 on 12/16/19 at 11:01 AM, revealed the resident was bored on the weekend as there was only one activity (Bingo for one hour) offered on Saturday and no activity other than church services on Sunday. The findings include: Review of the facility policy titled Group Programming, dated 05/02/19, revealed the purpose of the policy was to ensure each resident the opportunity for active participation in group programming designed to accommodate his or her social and/or cognitive abilities and to promote quality of life. Review of the record for Resident #1 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had been assessed to have a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident had been assessed to have moderately impaired cognition and was therefore interviewable. The MDS further revealed it was very important for Resident #1 to participate with group activities. Review of the comprehensive care plan for Resident #1 dated 01/28/19, revealed the resident enjoys visiting with a group of residents in the lobby or dining room. The care plan also revealed the resident enjoyed Bingo, cards, and other games. Review of the (MONTH) Activity Participation Record for Resident #1 dated (MONTH) 2019 revealed the only activity documented for Resident #1 for the month of (MONTH) on Saturdays was Bingo. The documentation did not include how long the activity lasted. The record did have a place to document the resident response to the activity, and an A was noted by each entry, which indicated active participation. Review of the facility activity calendar dated (MONTH) 2019 revealed the only activity listed for Saturdays was Bingo. Interview conducted with Resident #1 on 12/16/19 at 11:01 AM, revealed the resident stated, I would like to be able to assist with activities. I am a retired teacher. I feel I might be of use to the residents. I do not have any activities in the afternoon on Saturdays. I would like to see more games played. I have talked to the Activity Director (AD) in the past. Observation of Resident #1 on 12/16/19 at 11:30 AM revealed the resident was observed in the dining room playing Bingo. Group interview on 12/16/19 at 3:00 PM with Resident #20, Resident #38, Resident #15, Resident #32, Resident #37, and Resident #18, revealed they were provided with no activities on Saturdays except for Bingo for one (1) hour on Saturday mornings. The group revealed they had made the AD aware they wanted more activities on Saturdays and they were told they have no funding for more activities on the weekend and have no volunteers available to provide more activities. Interview conducted with the AD on 12/18/19 at 10:17 AM, revealed she had been aware Resident #1 had wanted more activities on Saturdays. The AD stated that in order to provide more activities on Saturdays she would have to cut an activity through the week to provide the staff. The AD stated she might have a volunteer who would be willing to work Saturday afternoon. Interview conducted with the Administrator on 12/18/19 at 10:44 AM, revealed staff had at times come in and provided activities on Saturdays. The Administrator stated she had not been aware there was a problem with not enough activities on Saturdays.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure the care plan for one (1) of eighteen (18) sampled residents was revised after a change in the resident's status. Resident #10 had a change in code status from do not resuscitate (DNR) to full code status per advance directive signed on 01/25/19. Review of the care plan did not reveal the update until 08/01/19. The findings include: Review of the facility policy, Care Planning and Interventions, dated 07/23/19, revealed the care plan was to be updated as needed, but no less than quarterly when conditions change. Observation of the resident on 12/17/19 at 11:24 AM, revealed the resident lying in bed with eyes closed. Further observation revealed a urinary catheter drainage bag hanging on the bed frame inside a dignity bag. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) annual assessment, dated 10/03/19, revealed a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was not able to respond to any of the interview appropriately. Further review of the record for Resident #10 revealed a Code Status form, which showed the family had signed for the resident to be a full code, dated 01/25/19. Review of the physician orders revealed an order dated 01/28/19 that stated Resident #10 was to be a full code. Review of the care plan revealed a care plan in the chart that identified that the advance directive for Resident #10 was a DNR, dated 01/05/19. Review of the care plan for Resident #10 in the electronic medical record (EMR) revealed the resident had an advance directive status of full code, revised date of 08/01/19. Further review of care plans in the EMR revealed care plan reviews dated 02/26/19, 03/14/19, 06/10/19, and 07/11/19, which showed Resident #10 to be DNR. Interview with the Assistant Director of Nursing on 12/17/19 at 12:07 PM, revealed the care plan on the chart was not the most recently updated care plan for Resident #10. She further stated the most recently updated care plan would be in the EMR. Interview with the MDS Nurse on 12/17/19 at 3:45 PM, revealed Resident #10's code status was not updated on the care plan until 08/01/19. Interview with the Administrator on 12/18/19 at 10:47 AM, after reviewing the care plans on Resident #10, revealed the care plan had not been updated to reveal the change in the advance directive from DNR to full code as indicated by a physician order dated 01/28/19, and the code status determination form dated 01/25/19. Interview with the Director of Nursing (DON) on 12/18/19 at 9:55 AM, revealed many things could lead to an update on the care plan. She stated physician orders or a change in condition would prompt that an update was needed for the care plan. She further stated she signs the MDS assessment for completeness, not for accuracy. She then added that the discipline that was responsible for completion of that area of the care plan would be the one to review for accuracy. Interview with the Social Services Director on 12/18/19 at 11:07 AM, revealed she would have been responsible for reviewing the care plan area related to advance directives for Resident #10. She stated she did miss that the resident's code status had not been updated on the care plan. She also stated she had no clue why she missed this.

Based on observation, interview, and facility policy/audit review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observation of the kitchen, on 09/27/18, revealed dished were not being stored properly. Review of the facility Census and Condition, dated 09/25/18, revealed fifty-four (54) of fifty-four (54) residents received their food from the kitchen. The findings include: Interview with the facility Administrator on 09/27/18 at approximately 3:30 PM, revealed she stated the facility did not have a specific policy related to the proper storing of dishes, but the facility followed the Federal Guidelines in regard to the proper storage of dishes. Observation of the kitchen dish room on 09/27/18 at 8:18 AM, revealed dozens of clean bowls to be used for the residents were being stored on a cart that was uncovered and the bowls were not stored inverted to prevent contamination. Interview with the Dietary Manager on 09/27/18 at 3:04 PM, revealed she stated she expect the dishes to be stored inverted or covered to prevent contamination.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure supervision and adequate assistance to prevent accidents for one (1) of sixteen (16) sampled residents (Resident #4). Resident #4 was assessed by the facility to require extensive assistance of two (2) staff for toileting on 06/18/18; however, on 07/06/18 only one (1) staff was providing toileting transfer assistance when Resident #4 fell . The findings include: Review of facility's policy titled, Fall Management, last issue (MONTH) (YEAR), revealed the purpose of the policy is to promote resident safety and reduce resident falls by proactively identifying, care planning and monitoring of residents' fall indicators. Further review of the policy, revealed based on comprehensive assessment of the resident, the facility must ensure that residents receive treatment and care in accordance with professional standard of practice, the comprehensive care plan and the resident's choice. Record review revealed the facility admitted Resident #4 on 04/02/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/18/18, revealed the facility assessed Resident #4's cognition to be intact with a Brief Interview for Mental Status Score of fifteen (15) which indicated the resident was interviewable. Further review of the 06/18/18 quarterly MDS assessment, revealed the facility assessed Resident #4 required extensive assistance of two (2) staff for toileting. Review of Resident #4's Fall Risk Evaluation sheet, revealed the most recent assessment done on Resident #4 prior to the fall on 07/06/18 was an assessment done on 05/03/18. Review of the Fall Risk Evaluation dated 05/03/18, revealed Resident #4's scored sixteen (16) which indicated this resident was a high falls risk. Further review revealed the facility assessed this resident, under mobility, on the Fall Risk Evaluation as having problems with ambulation, mobility and balance. Review of Resident #4's Activities of Daily Living Care Plan and At Risk for Falls Comprehensive Care Plan, related to history of Cerobvascular Accident and Impaired Mobility, dated 04/09/18 and last revised 06/18/18, revealed an intervention for staff to provide the amount of assistance/supervision that is needed to complete on the Activities of Daily Living Care Plan , instead of the assessed need of extensive assistance of two staff for toileting. The facility was unable to provide the Care Directives (CNA care plan) that was in place at the time of the fall. Review of the facility 'Incident Follow-up and Recommendation Form', dated 07/06/18, revealed Resident #4 fell on [DATE] while one (1) staff member was assisting Resident #4 with toileting. The immediate action listed on the incident form was to make Resident #4 a two person assist for toileting. Interview with Certified Nurse Aide (CNA) #2 on 09/27/18 at 2:37 PM, revealed Resident #4 was listed as requiring two staff assist for toileting transfers on the Care Directive at the time of the fall on 07/06/18. She stated she should have had a second person with her for the toileting transfer of Resident #4, but did not get another staff to help. She revealed she did not have a gait belt in use when Resident #4 lost his/her balance and fell , but she was supposed to be using one. Interview with the Director of Nursing (DON) on 09/27/18 at 1:03 PM, revealed she would expect staff to use the appropriate amount of assistance and the amount of staff required for toileting cares / needs that was assessed for the resident. She further stated she expects staff to use a gait belt with all transfers.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) resident not in the selected sample of sixteen (16) received foods that accommodated the resident's preferences (Resident 18). The facility assessed Resident #18 disliked black-eyed peas and black-eyed peas was listed as a dislike on the resident's meal card; however, on observation on 09/25/18,revealed the facility staff served black eyed peas to the resident. The findings include: Review of the facility policy titled, Food Preferences, last revised 01/01/07, revealed individual, cultural/religious food preferences are honored, when possible, to enhance the resident's satisfaction with food and dining. Further review of the policy revealed dislikes, food intolerance's/allergies [REDACTED]. Record review revealed the facility readmitted Resident #18 on 01/19/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 07/13/18 revealed the facility assessed Resident #18's cognition as intact, with a Brief Interview for Mental Status (BIMS) Score of fourteen (14), which indicated the resident was interviewable. Observation of meal service on 09/25/18 at 12:27 PM, revealed Resident #18's tray card indicated the resident disliked black-eyed peas; however, black-eyed peas were served to the resident. Interview with Resident #18 on 09/25/18 at 12:30 PM, revealed he/she did not like black-eyed peas and he/she wanted green beans instead. Resident #18 further stated he/she has been served dislikes on other occasions and he/she must bring it to staff's attention. Interview with Dietary Aide #1 on 09/27/18 at 12:35 PM, revealed she should have checked Resident #18's tray card prior to serving the black-eyed peas to the resident. She stated if she had noticed the dislike she would have made the kitchen aware. Interview with the Dietary Manager on 09/27/18 at 12:42 PM, revealed she expected the aide to have noticed the resident's dislikes prior to serving the food. She stated she had spoken with Dietary Aide #1 and she admitted it was an oversight on her part.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident who displays or is diagnosed with [REDACTED].#34). Record review revealed no documented evidence the facility developed and implemented person-centered care plans that included and supported the dementia care needs of Resident #34, whom had a [DIAGNOSES REDACTED]. The findings include: Interview with the Administrator on 09/27/18 at 3:53 PM, revealed the facility did not have a specific policy related to patient centered care planning and the facility follows State and Federal regulations in regards to patient centered care planning. Review of the facility policy, Resident Assessment Instrument (RAI) and Care Plan, last revised 11/28/16, revealed the RAI is not all inclusive, therefore, other sources of information are to be included when developing an individualized person-centered care plan for each patient that is reviewed by the interdisciplinary team with each assessment including the patient and other participants as the patient desires. Further review of the policy revealed the Care Plan includes measure objectives, timeframe's to meet the patient's cultural, nursing, mental, and psychosocial needs including services being provided to meet those needs. Record review revealed the facility readmitted Resident #34 on 07/06/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/05/18, revealed the facility assessed Resident # 34's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7). Review of Resident #34's Comprehensive Care Plan for Cognitive Loss related to Dementia, as evidence by (AEB) poor decision making abilities, dated 02/13/18, revealed goals for resident to maintain current level of cognition and be free from injury through next review. Further review revealed approaches to provide cues and reminders as needed, reorient/redirect as needed, call resident by name and identify self with each interaction, consult MD as needed, remind resident of facility policies as needed, remove items if noted, and call daughter as needed. However, the care plan did not reflect any individualized person-centered goals and interventions for Resident #34. Observation of Resident #34 on 09/25/18 at 11:14 AM, revealed he/she was in bed, lying on his/her back with eyes closed. Interview with the Minimum Data Set (MDS) Coordinator on 09/27/18 at 2:06 PM, revealed she is responsible for creating Dementia care plans. She further revealed Resident #34's care plan was very similar to other residents diagnosed with [REDACTED]. Interview with the Social Services Director on 09/27/18 at 2:23 PM, revealed she had received Dementia Care training, but not specifically related to care plans. She further stated dementia care plans for residents closely resembled one another. Interview with the Director of Nursing (DON) on 09/27/18 at 11:17 AM, revealed she expected all Dementia residents to have care plans specific to their needs. She stated the care plans are created to be specific for each resident including those residents with dementia, however, the care plans may resemble one another. Interview with the Administrator on 09/27/18 at 3:53 PM, revealed the resident Dementia care plans should be more person centered and specific to each resident.

Based on interview, record review, and facility policy review, it was determined the facility failed to complete a discharge summary and recapitulation of the resident's stay for one (1) of three (3) residents' closed records reviewed in the selected sample of sixteen residents (Resident #61). Resident #61 was discharged home on[DATE]; however, the facility did not complete a recapitulation of the resident's stay. The findings include: Review of the facility policy titled, Discharge Summary, last revised 07/24/17, revealed the discharge summary will contain a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. Record review revealed the facility admitted Resident #61 on 07/01/18 and discharged the resident home on 08/24/18. Further review of this resident's closed record, revealed no evidence of a complete recapitulation of this resident's stay. Interview with Medical Records Director on 09/26/18 at 2:57 PM, revealed she would expect the facility to ensure a complete recapitulation of stay to be done on all residents discharging home or community.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for one of sixteen (16) sampled residents (Resident #4). The facility failed to ensure the care plan for Resident #4 was reviewed and revised with care assistance information after a Quarterly Minimum Data Set (MDS) assessment was completed. The findings include: Review of facility's policy titled, Fall Management, last issued (MONTH) (YEAR), revealed the facility will implement a fall management system that results in reducing resident falls. The interdisciplinary team will review and revise, if indicated, all residents fall management care plans upon the completion of each comprehensive, significant change and quarterly Minimum Data Set (MDS) assessment, upon a fall event and as needed thereafter. Further review revealed the policy stated care plan revisions will be made at that time, as indicated. Record review revealed the facility admitted Resident #4 on 04/02/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 06/18/18, revealed the facility assessed Resident #4's cognition to be intact with a Brief Interview for Mental Status Score of fifteen (15) which indicated the resident was interviewable. Further review of the 06/18/18 quarterly MDS assessment, revealed the facility assessed Resident #4 required extensive assistance of two (2) staff for toileting. However, review of Resident #4's Activities of Daily Living Care Plan related to history of Cerobvascular Accident and Impaired Mobility, dated 04/09/18 and last revised on 06/18/18, revealed an intervention for staff to provide the amount of assistance/supervision that is needed to complete, instead of the assessed extensive assistance of two staff for toileting which would require staff to determine what the appropriate assistance they provide would be. In addition, review of Resident #4's At Risk for Falls Comprehensive Care Plan, dated 04/09/18 and last revised on 06/18/18, revealed there was no intervention or guidance listed for staff to know what type of assistance Resident #4 required for toileting transfers. The facility was unable to provide a copy of the Care Directive (CNA Care Plan) prior to the fall. Review of the facility 'Incident Follow-up and Recommendation Form', dated 07/06/18, revealed Resident #4 sustained a fall with no injuries on 07/06/18 while one (1) staff member was assisting Resident #4 with toileting. The immediate action listed on the incident form was to make Resident #4 a two person assist for toileting. Interview with MDS Coordinator on 09/27/18 at 02:30 PM, revealed she expected the MDS assessments to be completed accurately and reflect the resident's true status. She stated the care plans should match the MDS assessments. She further revealed she expected the care plans to be updated and reviewed/revised in between MDS assessments to reflect resident changes. Interview with the Director of Nursing (DON) on 09/27/18 at 1:03 PM, revealed she expected the care plan to show the required needs and assistance for each resident and it not have an intervention where staff would have to determine what type of or how much assistance to provide. She stated she would expect the MDS Coordinator to ensure the care plans reflect the MDS assessment when they are done and to review and revise the care plans ongoingly as needed. Interview with Facility Administrator on 09/27/18 at 1:22 PM, revealed she expected the care plans to reflect the required needs and assistance the residents required based on their MDS assessments. She stated she expected the MDS Coordinator to ensure the care plans match the MDS assessments and to review and revise the care plans in between assessments to continually reflect the residents' status.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the Comprehensive Care Plan was reviewed and revised for two (2) of sixteen (16) sampled residents (Resident #1 and Resident #2). The facility failed to revise the care plan for pain for Resident #1 and for pressure sores for Resident #2. The findings include: Review of the facility's policy Resident Care Plan, last revised December 2008, revealed the review of the care plan was done, at least quarterly and as needed, to reflect the resident's current needs, problems, goals, care, treatment and services. 1. Record review revealed the facility admitted Resident #1 on 01/22/14 with [DIAGNOSES REDACTED]. Observation of a skin assessment for Resident #1 completed by Registered Nurse (RN) #2 , on 07/07/16 at 9:45 AM, revealed the nurse identified a Stage I pressure ulcer to the coccyx area. Resident #1 jerked and called out in pain when RN #2 palpated the area. Review of Resident #1's Comprehensive Care Plan revealed the care plan was not revised to address the resident's identified pain related to a Stage I pressure ulcer identified on 07/07/16. Interview with RN #2, on 07/08/16 at 1:20 PM, revealed she should have updated the care plan related to the pain. Interview with Director of Nursing (DON), on 07/08/16 at 1:40 PM, revealed she expected the care plan to have been updated per facility policy. 2. Record review revealed the facility admitted Resident #2 on 03/26/13 with diagnoses, which included [MEDICAL CONDITION], Hypertension, Anxiety, Depression, and [MEDICAL CONDITION]. Review of the quarterly MDS assessment, dated 06/15/16, revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Observation on 07/07/16 at 9:25 AM, revealed RN #2 applied a Duoderm patch to the inner left buttock area of Resident #2, after Certified Nurse Aide (CNA) #1 completed incontinent care. Review of the Treatment Administration Record (TAR) for the month of July 2016, revealed an order dated 07/05/16, for Duoderm to have been applied to the left buttock, to check placement each shift and to change every three (3) days and PRN (as needed). Review of the Impaired Skin Integrity Care Plan on 07/07/16 at 10:15 AM, with an onset date of 10/16/15, revealed no documented evidence the care plan was revised to address the Stage II pressure ulcer identified on 07/05/16. Interview with RN #2, on 07/07/16 at 10:10 AM, revealed she came in to the resident's room to apply the Duoderm dressing; after CNA #1 informed her she was finished with incontinent care for Resident #2. RN #2 stated the area was not due to be measured on that day but she would consider the area on Resident #2 to be about the size of a Silver dollar and would have classified it as a Stage Two (2), because it was open and the top layer of skin was missing. Further interview revealed when a new area was identified, the care plan should have been updated to address the new pressure ulcer. Interview with RN #1 on 07/07/16 at 11:30 AM, revealed she spoke with the covering physician for Resident #2 when he was in the building on 07/05/16. She stated the physician ordered the Duoderm to be applied to the left buttock, placement checked each shift and the dressing to have been changed every three (3) days and PRN (as needed.) The RN stated she placed the order on the TAR, but failed to update Resident #2's care plan to address the new wound area. Interview with the Assistant Director of Nursing (ADON) on 07/07/16 at 2:00 PM, revealed she would have expected RN #1 to have updated the care plan to address the newly identified wound. Interview with the Director on Nursing (DON), on 07/08/16 at 1:35 PM, revealed she expected the nurse to revise the care plan when the nurse identifies a new or worsening pressure area.

Based on observation, interview, and record review, it was determined the facility failed to notify the physician in a timely manner related to a new onset of pain for one (1) of sixteen residents (Resident #1). Resident #1 complained of pain to the coccyx during a skin assessment on 07/07/16; and a Stage I pressure ulcer was identified at the site; however, when the nurse made the physician aware of the newly identified pressure sore she did make the physician aware of the resident's pain with palpitation of the wound. The findings include: 1. Record review revealed the facility admitted Resident #1 on 01/22/14 with diagnoses, which included History of Traumatic Fracture of Vertebrae, Major [MEDICAL CONDITIONS], Anorexia, Dementia, and [MEDICAL CONDITION] Fibrillation. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/06/16, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review revealed the resident was able to have made him/herself understood and had the ability to understand others. Observation made during a skin assessment of Resident #1, on 07/07/16 at 9:45 AM, revealed Registered Nurse (RN) #2 assessed the resident's buttocks and coccyx area and identified a ten (10) centimeters (cm) reddened area to coccyx, with a dime size Stage I decubitus on coccyx. Further observation revealed when RN #1 palpated the area, Resident #1 yelled out in pain and stated, That hurts. Review of Nurses Notes, dated 07/07/16, revealed there was no documented evidence RN #2 notified the physician of the resident ' s complaints of pain. Interview with RN #2, on 07/08/16 at 4:15 PM, revealed she did not make the physician aware of the pain. Interview with Assistant Director of Nursing (ADON), on 07/08/16 at 11:42 AM, revealed she could not find any notation in the resident's record regarding a call to the physician about the pain found during skin assessment. She stated she expected the nurse to have made the physician aware of the resident's pain at the site of the pressure ulcer. Interview with Director of Nursing (DON), on 07/08/16 at 1:40 PM, revealed she expected the nursing staff to have notified the resident's physician of the resident's pain identified at the pressure ulcer site.

Based on observation, interview, record review and facility policy review, it was determined facility failed to ensure a resident who has developed a pressure ulcer receives the necessary treatment and services to promote healing and prevent infection for one (1) of sixteen (16) sampled residents (Resident #2). Resident #2 was identified to have a Stage II pressure ulcer to the left outer coccyx on 07/05/16. However, the facility failed to ensure the new wound was identified on the Pressure Ulcer Status Record to ensure the wound was assessed weekly; and addressed on the Comprehensive Care Plan, to ensure appropriate treatment was provided and the wound was improving. The findings include: Review of facility policy, titled Evaluations, Screenings, and Assessments from Chapter two (2) of Pressure Ulcer Prevention, Wound Care Resource Manual, last revised 02/25/15, revealed Ulcers that are present, or which develop after admission, are treated according to medical orders. Weekly wound assessments are performed and recorded on the Pressure Ulcer Status Record in the patient's medical record. Review of facility policy, titled Treatment Orders from Chapter four (4) of Wound Care Resource Manual, last revised 02/25/15, revealed if a patient has multiple wound sites, a complete and separate treatment order must be written for each site. Each site and order should be numbered to assist with the tracking the improvement of each site. After observation/evaluation of the affected skin area, the physician is notified. The physician order [REDACTED]. Record review revealed the facility admitted Resident #2 on 03/26/13 with diagnoses, which included [MEDICAL CONDITION], Hypertension, Anxiety, Depression, and [MEDICAL CONDITION]. Review of the quarterly MDS assessment, dated 06/15/16, revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Further review revealed the resident required extensive assistance of two (2) for bed mobility and was at risk for developing pressure ulcers. Observation, on 07/07/16 at 9:25 AM, revealed RN #2 applied a Duoderm patch to the inner left buttock area of Resident #2, after Certified Nurse Aide (CNA) #1 completed incontinent care. Review of the Treatment Administration Record (TAR) for the month of July 2016, revealed the wound was identified on 07/05/16, and for Duoderm to have been applied to the left buttock, to check placement each shift and to change every three (3) days and PRN (as needed). Review of the Impaired Skin Integrity Care Plan, on 07/07/16 at 10:15 AM, with an onset date of 10/16/15, revealed no documented evidence the care plan was revised/updated to address the newly identified Stage II pressure ulcer identified on 07/05/16. In addition, review of the Facility's Wound Book at the South Nurse's Station, revealed, no documented evidence of a current Pressure Ulcer Status Record identifying the pressure ulcer, it's size and characteristics. Interview with RN #1, on 07/07/16 at 11:30 AM, revealed she spoke with the covering physician for Resident #2 when he was in the building on 07/05/16. She stated he had ordered the Duoderm to have been applied to the left buttock, placement checked each shift and the dressing to have been changed every three (3) days and PRN (as needed.) RN #1 stated she placed the order on the TAR, but failed to measure the wound and document on the Pressure Ulcer Status Record. RN #1 revealed she would classify the wound area to be a Stage Two (2), as there was a top layer of skin missing; was about the size of a silver dollar with no jagged edges; and the area was solid round with no depth. Further interview revealed she failed to update Resident #2's care plan to address the new wound area. Interview with RN #2, on 07/07/16 at 10:10 AM, revealed she came in to the resident's room to apply the Duoderm dressing, after CNA #1 informed her she was finished with incontinent care for Resident #2. RN #2 stated the area was due to be measured on that day but she would consider the area on Resident #2 to be about the size of a silver dollar and would have classified it as a Stage Two (2), because it was open and the top layer of skin was missing. Further interview revealed the RN was unaware there was no current Pressure Ulcer Status Record in the wound book, as she was not the nurse who identified the area. RN #2 stated when a new area was identified, the area should be assessed, measured, and documented on the Pressure Ulcer Status Record and the physician and family were to have been notified and the care plan should have been updated to address the newly identified pressure area. Interview with the Assistant Director of Nursing (ADON), on 07/07/16 at 2:00 PM, revealed she would have expected RN #1 to have measured and documented the area on the Pressure Ulcer Status Record, made a progress note, and updated the care plan to address the newly identified wound. The ADON stated she became aware of this concern today, and she assessed, measured, and documented the measurements on the Pressure Ulcer Status Record for Resident #2. The ADON stated, she classified the area on the inner left buttock as a Stage Two (2), as there was a top layer of skin missing, the area measured 4.2 centimeters (cm) x 2.8 centimeters (cm,) with no measurable depth, drainage and no odor. Interview with the Director on Nursing (DON), on 07/08/16 at 1:35 PM, revealed when a nurse identifies a new or worsening pressure area, she expected the nurse to assess the area, call the physician, and describe the area, and obtain an order for [REDACTED].

Based on observation, interview, record review, review of narcotic count sheet, and review of the facility's policy and procedures, it was determined the facility failed to ensure services provided met professional standards of quality for one (1) of sixteen (16) sampled residents (Resident #2) and one (1) unsampled resident (Resident A). Staff failed to have a written order to treat Resident #2's pressure ulcer. In addition, the nurse signed out a narcotic medication for Unsampled Resident A one (1) hour before the medication was due. A count of the medication revealed the dose had not been administered. The findings include: 1. Review of the facility policy and procedure, titled Physician's Orders/Transcription, last revised 10/04, revealed medications and treatments ordered by the physicians or other Licensed Independent Practitioners, including telephone orders, may have been obtained by a licensed nurse, but must have been signed by the physician. When there is a verbal order , the qualified associate taking the order writes down the order (including the purpose, diagnosis, or indication for use) and then reads it back verbatim to the practitioner who initiated it. The practitioner who initiated the order should then verbally confirm that the order is correct. Record review revealed the facility admitted Resident #2 on 03/26/13 with diagnoses, which included [MEDICAL CONDITION], Hypertension, Anxiety, Depression, and [MEDICAL CONDITION]. Observation, on 07/07/16 at 9:25 AM, revealed Registered Nurse (RN) #2 applied a Duoderm patch to the inner left buttock area of Resident #2, after Certified Nurse Aide (CNA) #1 had completed incontinent care. However, review of the Physician Orders for July 2016, revealed no evidence of an order for [REDACTED]. Review of the Treatment Administration Record (TAR) for the month of July 2016, revealed documentation for Duoderm dressing applied to left buttock check placement each shift. Change every three (3) days and PRN (as needed), which was initiated on 07/05/16. Interview with RN #2, on 07/07/16 at 10:10 AM, revealed after reviewing Resident #2's clinical record, the RN stated she verified there was no written order for Resident #2's Duoderm and the only written documentation was written on the TAR and she stated, We have no standing orders for Duoderm and a written physician order was required . Interview with RN #1, on 07/07/16 at 11:30 AM, revealed she spoke with the covering physician for Resident #2, when he was in the building on 07/05/16. She stated the physician ordered Duoderm to have been applied to the left buttock, to check placement each shift, and to change the dressing every three (3) days and PRN (as needed.) The RN stated she placed the order on the TAR, but failed to write an order in Resident #2's medical record after speaking with the physician. Interview with the on call Physician (for Resident #2), on 07/08/16 at 1:35 PM, revealed he did speak with RN #1 about Resident #2. However, he stated he would have expected a written order to be in the clinical record. Interview with the Assistant Director of Nursing (ADON), on 07/07/16 at 2:00 PM, revealed she would have expected RN #1 to write out a physician order. Interview with the Director on Nursing (DON), on 07/08/16 at 1:35 PM, revealed she would have expected the nurse to write out a physician order after speaking with the physician. 2. Review of the policy and procedure for Controlled Drugs, revised February 2013, revealed the nurse signs off each dose of the controlled drug given by documenting: the date; the hour; the resident name; the physician; the amount dispensed; the signature of the nurse; and the balance after subtracting the amount dispensed. Observation of a narcotic count, comparing the multi-dose pack medication counts with the amount of medications left to administer on the Narcotic Count Sheet, with Registered Nurse (RN) #3, on the 300 Wing, on 07/08/16 at 10:55 AM, revealed Unsampled Resident A required [MEDICATION NAME] 7.5- 325 milligrams (mg,) four times a day for pain relief. A review of the Narcotic Count Sheet at 11:00 AM, revealed the 12:00 noon dose of [MEDICATION NAME], dose number eleven (11), had been signed out as given and there were ten doses left on the sign-out sheet. Observation of the multi-dose blister pack of medications revealed there were still eleven (11) doses left on the blister pack. Interview with RN #3, on 07/08/16 at 11:10 AM, revealed she had not given the noon dose and stated she should not have signed out the medication prior to administration and the narcotics should be signed out when they are administered. Interview with the Administrator, on 07/08/16 at 11:25 AM, revealed the narcotics should be signed out when they are administered and not before or after administration.

Based on observation, interview and facility policy review, it was determined the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection on one (1) of three (3) resident halls. Two (2) Certified Nurse Aides (CNAs) failed to sanitize their hands in between each tray passed during meal pass on the 300 hall. The findings include: Review of the facility policy titled, Hand Hygiene, dated 05/01/12, revealed hand washing was to decrease the risk of transmission of infection. Visible dirty or contaminated hands should be washed with antimicrobial soap and water. If hands are not viably soiled, an alcohol-based hand sanitizer may be used. 1. Observation of resident hallway 300 meal tray pass, on 06/15/15 at 7:38 AM, revealed Certified Nurse Aide (CNA) #1 passed resident meal trays into three (3) different resident rooms and failed to wash or sanitize her hands at anytime. Interview with CNA/Restorative Aide #1, revealed hand washing should occur between every passing of a resident meal tray. She stated the staff was allowed to use hand sanitizer between three (3) residents then they must wash their hands with soap and water. She stated she failed to follow this policy during the meal pass. She showed the surveyor she was carrying hand sanitizer in her pocket; however, indicated she failed to use any form of hand sanitizer. 2. Observation of resident hallway 300 meal tray pass, on 06/14/15 at 12:33 PM, revealed CNA #2 passed resident meal trays into four (4) different resident's rooms and failed to sanitize or wash her hands at anytime. Interview with Licensed Practical Nurse (#1), on 06/16/15 at 8:20 AM, revealed she expected any staff who was passing meal trays to sanitize their hands in between each tray pass. Interview with the Assistant Director of Nursing (ADON), on 06/16/15 at 7:55 AM, revealed she expected the staff to use hand sanitizer with each meal pass and to wash with soap and water after each three (3) uses of the alcohol-based hand sanitizer. She stated not doing this could result in the spread of infection. Interview with the Director of Nursing (DON), on 06/16/15 at 8:15 AM, revealed she expected staff to sanitize their hands in between each tray pass and after three (3) uses of the hand sanitizer she expected the staff to wash their hands with soap and water.

Based on observation, interview and review of facility policy, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible as evident by a green E oxygen cylinder being stored in a standing position on the floor unsecured behind a motorized wheelchair on one (1) of three (3) resident halls (hall 300). The motorized wheelchair was blocking the fire extinguisher and the emergency fire pull alarm outside Room #301 and a standard wheelchair was blocking the fire extinguisher and emergency fire pull station at the opposite end of the hall by Room #320. The findings include: Review of the facility's policy titled, Oxygen Use, General, dated 02/2011, revealed oxygen cylinders must be stored in racks with chains, sturdy portable carts, and/or approved stands. Additionally, Oxygen cylinders may not be stored in any resident's room or living area and cylinders may not be left freestanding, they must be securely fastened all times. Observation during general tour of the 300 Hallway, on 06/14/15 at 12:03 PM, revealed a green E size oxygen cylinder standing freely on the floor and unsecured behind a motorized wheelchair outside resident room #301. The wheelchair was blocking the emergency fire pull station and the fire extinguisher. Further observation revealed a standard manual wheelchair was stored at the opposite end of the hall by resident room #320 which was blocking the fire extinguisher and emergency fire pull station. Interview, on 06/14/15 at 2:02 PM with the Maintenance Director, revealed the oxygen tank stored at the end of the (300) hallway by resident room #301 should not be there. The Maintenance Director stated the oxygen must be secured at all times. Additionally, he revealed the wheelchairs should not be stored in a manner that blocked the emergency fire pull station or fire extinguisher. Interview, on 06/14/15 at 2:05 PM with the Administrator, revealed she expected all oxygen cylinders to be secured and never left free standing and there should never be anything blocking the emergency fire pull station or fire extinguisher.

Based on interview, record review, review of the facility's policy and procedure and Plan of Correction for the 02/11/14 Abbreviated Survey, it was determined the facility's Quality Assessment and Assurance Committee failed to ensure the education provided to licensed staff on medication administration was effective. Per the facility's Plan of Correction, for the survey dated 02/11/14, all licensed nurses received education on two (2) occasions on the five (5) rights (right resident, right time, right medication, right dose, and right route) of medication administration. However, a licensed nurse failed to remove a [MEDICATION NAME] prior to the application of a new patch to ensure the resident received the right dose of medication for one (1) of fifteen (15) sampled residents (Resident #15). During an Abbreviated Survey concluded on 02/11/14, Immediate Jeopardy was identified at 483.20 Resident Assessment F-281 Services Meet Professional Standards; and 483.25 Quality of Care, F-333 Free of Significant Medication Error. The facility submitted a Plan of Correction for the 02/11/14 survey; however, additional investigation during the Standard Recertification, Revisit and Abbreviated Survey concluded on 04/09/14 revealed the residents continued to be at risk for significant medication errors. Immediate Jeopardy was identified at 483.20 Resident Assessment, F-281; 483.25 Quality of Care, F-333 Free of Significant Medication Error; and, 483.75 Administration, F-490 Administration and F-520 Quality Assessment and Assurance. On 01/14/14, Resident #15 was readmitted to the facility with a [MEDICATION NAME] in place and a physician's orders [REDACTED]. On 01/17/14, the facility applied a new [MEDICATION NAME]; however, there was no documented evidence the old [MEDICATION NAME] was removed. On 01/18/14, Resident #15 was found staring blankly and with minimal response to verbal stimuli. The physician was notified and a fifty (50) microgram (mcg) [MEDICATION NAME] Patch was removed from the resident's chest at the facility. The resident was sent to the emergency room for evaluation. Review of hospital documentation revealed a [MEDICATION NAME] Patch was also removed in the emergency room . The resident was administered a dose of [MEDICATION NAME] (Opiate drug reversal drug) 0.4 milligrams (mg) via IV piggyback and the resident woke up and stated his/her name to the emergency room Nurse. Resident #15 was admitted to the Intensive Care Unit (ICU), on 01/19/14 at 12:03 AM, with a primary [DIAGNOSES REDACTED]. The licensed staff had failed to remove the previous [MEDICATION NAME] prior to applying a new patch to ensure the resident received the right dose of medication. The facility's Quality Assurance failed to identify this error as a significant medication error and failed to put corrective actions in place. The facility's failure to develop and implement appropriate plans of action to correct identified quality deficiencies has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/03/14 and was determined to exist on 01/17/14. The facility was notified of the Immediate Jeopardy on 04/03/14. An acceptable Allegation of Compliance was received on 04/08/14, alleging the removal of the Immediate Jeopardy on 04/08/14. The State Survey Agency validated, on 04/09/14, the Immediate Jeopardy was removed on 04/08/14, as alleged. The Scope and Severity was lowered to a "D" at 42 CFR 483.20 Resident Assessment F-281 and 42 CFR 483.25 Quality of Care F-333 ; and, 483.75 Administration, F-490 and F-520 while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure, "Performance Improvement Plan", revised 11/23/09, revealed, "The facility implements and maintains an ongoing program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality care, and resolve identified problems." The purpose includes, "to establish and provide a system whereby a specific process and the documentation relative to it is maintained to support evidence of an ongoing Performance Improvement Program, encompassing all aspects of resident care, including safety, infection control, and quality of life applicable to nursing facility residents." Review of the facility's Plan of Correction (POC), for the survey dated 02/11/14, revealed all licensed staff was educated on the five (5) rights of medication administration and a post competency test related to medication administration was given. The five (5) rights of medication administration were: 1.) Right Resident, 2.) Right Drug, 3.) Right Dose, 4.) Right Time and, 5.) Right Route. However, when conducting the Standard Recertification Survey, Revisit Survey, and the Abbreviated Survey it was determined the training was ineffective and the residents remained at risk for significant medication errors. The facility failed to have an effective system in place to ensure staff was knowledgeable in the placement and removal of medication [MEDICATION NAME]es to ensure the medication was administered at the right dose. Further review of the Plan of Correction revealed, "if any nurse does not follow the proper procedures for medication administration, they will be immediately removed from patient care area and re-educated by DON, ADON. However, the facility's Quality Assurance failed to identify the 01/17/14 medication error as an significant medication error and failed to put corrective actions in place. Further review of the Plan of Correction revealed "all residents unless discharged had one or more physician visits between 11/28/13 and 02/05/14, physician visits constituted review of vitals, assessments and abnormal findings and plan of treatment, if needed; no resident was identified for any change of condition due to a medication error." However, review of Resident #15's medical record revealed there was no documented evidence Resident #15 was assessed by the physician per the Plan of Correction. On 01/14/14 Resident #15 was administered a fifty (50) mcg [MEDICATION NAME] Patch prior to the resident being discharged to the nursing facility. Review of the facility's admission orders [REDACTED]. Review of Resident #15's January 2014 MAR revealed the facility applied a [MEDICATION NAME] 50 mcg Patch on 01/17/14; however, further review of the MAR and the resident's record revealed there was no documented evidence of the old patch being removed to ensure the resident would receive the right dose of medication. On 01/18/14, Resident #15 was found staring blankly and with minimal response to verbal stimuli. The resident was sent to the emergency room for evaluation and was admitted to the Intensive Care Unit (ICU), on 01/19/14 at 12:03 AM, with a primary [DIAGNOSES REDACTED]. The licensed staff had failed to remove the previous [MEDICATION NAME] prior to applying a new patch to ensure the resident received the right dose of medication. Interview with the Staff Development Coordinator (SDC), on 05/09/14 at 10:03 AM, revealed she was present during the QA meeting related to the significant medication error (related to medication given to the wrong resident). She stated measures were discussed and interventions were put in place to prevent future medication errors. However, the facility's QA failed to identify the 01/17/14 medication error as another significant medication error. Interview with the Social Services Director (SSD), on 05/09/14 at 9:20 AM, revealed she was a member of the Quality Assurance Committee. She stated the committee did not identify a system's failure related to the QA process which may have led to the second medication error. Interview with the Director of Nursing (DON), on 05/09/14 at 9:51 AM, when asked about the 01/17/14 medication error, she stated, "we did not have a second medication error; therefore, our QA process did not fail." Additionally, she stated there have been changes made to the admission's process to reflect an additional place to document patches on admission. A Post Survey interview with the DON, on 05/20/14 at 1:45 PM, revealed the licensed staff should remove the old [MEDICATION NAME] prior to applying a new patch to ensure the right dose of medication was administered per physician's orders [REDACTED]. Interview with the Executive Director (ED), on 05/09/14 at 9:06 AM, revealed in the Quality Assurance (QA) meeting incidents and accidents were reviewed, and if a system's problem was identified, recommendations for a plan were made to correct the problem. Additionally, she stated she did not believe there was a second significant medication error, and the QA measures put in place after the first significant medication error were effective. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/15/14, Resident #15 was discharged home with family and no longer resides at the center. The facility initiated an internal investigation at the time the resident was readmitted on [DATE] and was identified as having an accidental narcotic overdose. The DON, ADON, SDC, and Regional Director of Clinical Services (RDCS) conducted a medication pass audit which included administration, rotation, and patch presence on 02/01/14 and 02/06/14. No discrepancies were identified and the audits were on-going. On 04/07/14, the DON and RDCS completed a validation to ensure that all nine (9) residents with any type of [MEDICATION NAME] had the location of the patch on the resident documented on the MAR and that all medications were being administered per physician's orders [REDACTED]. On 01/24/14, two (2) additional residents were identified as receiving [MEDICATION NAME]es to treat pain. The DON verified the physician's orders [REDACTED]. [MEDICATION NAME]es were audited by the DON on 01/24/14 for all residents with orders to verify the patch count was accurately reflective of the narcotic count sheet. On 04/03/14, the RDCS and the DON reviewed the documentation of the residents with [MEDICATION NAME]es (two residents from 01/23-02/06/14, two (2) residents from 02/06-02/07/14, three (3) residents from 02/07/14-present). The [MEDICATION NAME] orders and January to present MARs reflected the resident's patches were applied per physician's orders [REDACTED]. Residents who had an order for [REDACTED]. The Pharmacist conducted a review of all current [MEDICATION NAME] orders and counts were correct on 02/04/14. She also reviewed the documentation of the location of the patch on the MARs and verified each shift placement check. On 01/31-02/02/14, all licensed nurses were provided education on medication administration including [MEDICATION NAME]es. This education was completed by the DON and the Staff Development Coordinator (SDC) and was provided for 100% of the licensed nurses before midnight on 02/02/14. On 04/03/14, the RDCS completed education for the Executive Director, DON, Assistant Director of Nursing (ADON), SDC, and the Minimum Data Set Coordinator (MDSC) which included: ? [MEDICATION NAME] administration/removal policy and procedure ? Required documentation of the [MEDICATION NAME] removal and application, including anatomical location of patch to be on the MAR. ? Admission documentation in admission assessment/notes to include [MEDICATION NAME]es present and the location. ? Notification of DON or ADON upon receipt of new [MEDICATION NAME] orders received. All licensed nurses received the above training beginning on 04/03/14. Education was completed by the DON, ADON, or MDS Nurse. Education included a quiz which required a score of 100% to validate competency. This education was completed with 100% of licensed staff on 04/04/14. Any licensed nurse who did not receive the above training would not be allowed to work until the training was completed. The DON, ADON, MDS Nurse, and SDC provided education to the Certified Nursing Assistants (CNAs) to include observing for [MEDICATION NAME]es during activity of daily living (ADL) care and to notify the Charge Nurse if more than one (1) patch was identified on the resident. Education was initiated on 04/04/14 and was completed prior to midnight to all staff on duty. Any staff who did not receive the training prior to midnight on 04/04/14 was to receive the training prior to beginning his/her next working shift. Nursing will notify the DON or ADON at the time of all new [MEDICATION NAME] orders received. On 04/03/14, the DON and ADON completed audits of residents' records who were receiving a [MEDICATION NAME] for documentation of placement on the MAR and verified the patch was located on the resident in accordance to the assessed, documented site. The DON, ADON, and RCDS reviewed resident records who currently had [MEDICATION NAME]es to validate the physician's orders [REDACTED]. Beginning 04/04/14, the DON, ADON, SDC, Unit Manager, MDS Nurse and/or RDCS will validate the [MEDICATION NAME]es orders are correct, recorded on the MAR, location will be documented on the MAR, and verify the patch is located on the resident in accordance with the assessed, documented site. The process was to occur seven (7) days a week for thirty (30) days, then would be completed four (4) times a week for thirty (30) days. If a discrepancy was identified, the nurses involved would not be allowed to administer medications until they were retrained and deemed to be competent in medication administration. The DON, ADON, SDC, or Unit Manager will monitor the next five (5) admissions with a [MEDICATION NAME] order beginning on 04/05/14, and again on 04/07/14 to ensure [MEDICATION NAME] orders were recorded on the MAR correctly, the location was documented on the MAR and on the initial data collection tool. They will verify the patch was on the resident as the MAR indicated. If a discrepancy was identified, the nurses involved would not be allowed to administer medications until they were retrained and deemed to be competent in medication administration. All audit and monitoring outcomes would be presented to and reviewed by the Performance Improvement (PI) Committee for revision or plan recommendations. Audits would be completed seven (7) days a week, for the next thirty (30) days, then at a rate of four (4) times per week for thirty (30) days. The PI Committee would meet weekly over the next thirty (30) days, then bi-weekly for thirty (30) days to review results. PI meetings were held on 02/05, 02/06, 02/12, 02/19, 02/26, 03/05, 03/07, 03/09, and 03/19/14. Review of education provided in regard to medication administration as well as full review of completed medication administration audits were conducted at each PI meeting. On 04/03/14, the Medical Director and the resident's attending physician were notified of Immediate Jeopardy and the facility's action plan and both agreed with the action plan. The PI Committee met on 04/04/14 to review the action plan, validate education as completed, and to update the Medical Director on the additional documentation for new admissions on the initial data collection tool and to validate monitoring was in place. The PI Committee consists of the Executive Director, DON, ADON, SDC, MDS Nurse, Social Services, and Activity Director. The PI Committee was to meet weekly for thirty (30) days to review all audits, new admissions with [MEDICATION NAME]es, and revise the care plans to ensure resident's individual needs were met and residents were receiving care to meet the highest practicable well being. The PI Committee was to meet two (2) times a month for thirty (30) days, then monthly to review all audit findings and make revisions as needed to the action plan based on audit findings. **The State Survey Agency validated the corrective action taken by the facility as follows: Record review revealed Resident #15 was discharged home with family on 03/15/14. Review of Medication Pass Audits, dated 02/01/14 and 02/06/14 revealed the DON, ADON, SDC, and RDCS conducted a medication pass audit and monitored the entire medication pass including the administration of medication patches to include ensuring the rotation of sites for the patches, patches were dated and timed, as well as documented on the MAR for placement and removal of the old patch. Random patch audits were ongoing and continued to be performed three (3) times a week. Review of the MAR audit list, dated 04/07/14, revealed the DON and RCDS completed observations of the nine (9) residents with any type of [MEDICATION NAME] to ensure the patch was located at the same site as was documented on the MAR. In addition, they reviewed the physician's orders [REDACTED]. Review of the Physician's Progress Notes, dated 04/03/14, for Resident #10 and Resident #3 revealed both residents were assessed and received [MEDICATION NAME]es with no adverse side effects noted. Review of a Medication Audit form, dated 04/04/14, revealed the pharmacists reviewed the MARs for Resident #3 and Resident #10 for correct documentation for placement, checks, application, removal, and disposal of [MEDICATION NAME]es with no concerns noted. Review of the inservice log, dated 01/31/14-02/02/14, revealed 100% of licensed staff was inserviced and a post test was completed to verify competency of [MEDICATION NAME] administration by the DON and SDC. Review of training, dated 04/03/14, revealed 100% of licensed staff was inserviced on the procedure for Admission/Readmission of residents utilizing [MEDICATION NAME]es by the DON, ADON, SDC, and MDS Coordinator. The training included [MEDICATION NAME] administration and removal policy and procedure; the required documentation of patch removal and application, including location of the patch; the documentation on Admission Assessments and Notes should include if any patches present and the location of the patches; and Notification of the DON and/or ADON upon receipt of new patch orders. A competency exam was given to verify the understanding of the training. 100% of licensed staff was inserviced and new hires will receive the same training. Review of the CNA training log, dated 04/04/14, revealed a phone training was completed by the Regional Nurse Consultant on 04/04/14 which included to observe for patches during care and to utilize a "stop and watch" tool to report areas to the charge nurse. Interviews with RN #2, RN #4, RN #10, RN #11, LPN #1, LPN #5, LPN #6, LPN #7, LPN #8, and LPN #10, on 04/09/14 between 10:15 AM and 10:45 AM, revealed they were trained on the disposal process for [MEDICATION NAME]es, documentation of the site of the patch on the resident, physician notification if more than one (1) patch was found on a resident, and the process of documenting patches on new admissions. Additionally, RN #2, RN #4, RN#10 and RN #11 were educated on the notification of the Director of Nursing and/or the Assistant Director of Nursing of new orders for [MEDICATION NAME]es, the admission process for [MEDICATION NAME]es documentation, placement checking of the patch and to complete a complete body audit if the patch was not where it was supposed to be and conduct an investigation, and the disposal process for the patches which includes two (2) licensed nursing staff to witness and destroy the patch by folding it and placing it in a Sharp's container. Interviews with CNA #1, CNA #2, CNA #3, and CNA #4, on 04/09/14 between 10:15 AM and 10:45 AM, revealed they were inserviced on reporting to the Charge Nurse if while performing care to a resident, two (2) patches were found to be present on the resident. They stated they would fill out a "Stop and Watch" form and turn it in to the Charge Nurse. Review of the [MEDICATION NAME] Patch Audits, on 04/08/14 and 04/09/14 revealed all new [MEDICATION NAME] orders were reported to the DON and/or ADON. The DON and ADON completed audits of residents who were currently on a [MEDICATION NAME] of any kind with the last audit completed on 04/08/14 and to continue every day for seven (7) days. The facility did not have any new admissions on [MEDICATION NAME]es at this time. On 04/03/14, the Medical Director was notified of the AoC and agreed with the plan with a verified signature. Review of the Quality Assurance meeting notes, dated 01/01/14, revealed the AoC was discussed via a phone call between the Medical Director and the Executive Director. Review of the PI Committee meeting documentation, dated 01/01/14 through 03/19/14 revealed meetings were held weekly to review all audits, new admissions with [MEDICATION NAME]es, and revise the care plans to ensure resident's individual needs were met and residents were receiving care to meet the highest practicable well being. Interviews conducted with the ADON, DON, and the Executive Director, on 04/09/14, revealed medication administration was discussed in the PI meetings as stated in the AoC and training was provided to licensed nursing staff as well as the CNAs related to identifying multiple patches on residents or a patch on a resident on initial admission to the facility.

Based on interview, review of the Executive Director's (ED) job description, and review of the facility's policy and procedure and Plan of Correction for the 02/11/14 Abbreviated Survey, it was determined the facility failed to have an effective system to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of fifteen (15) sampled residents (Resident #15). During an Abbreviated Survey concluded on 02/11/14, Immediate Jeopardy was identified at 483.20 Resident Assessment F-281 Services Meet Professional Standards; and 483.25 Quality of Care, F-333 Free of Significant Medication Error. The facility submitted a Plan of Correction for the 02/11/14 survey; however, additional investigation during the Standard Recertification, Revisit and Abbreviated Survey concluded on 04/09/14 revealed the residents continued to be at risk for significant medication errors. Immediate Jeopardy was identified at 482.20 Resident Assessment, F-281; 485.25 Quality of Care, F-333 Free of Significant Medication Error; and, 483.75 Administration, F-490 Administration and F-520 Quality Assessment and Assurance. The facility failed to have an effective system in place to monitor the placement and removal of medication [MEDICATION NAME]es and failed to identify if [MEDICATION NAME]es were in place on admission to ensure the medication was administered at the right dose for one (1) of fifteen (15) sampled residents (Resident #15). In addition, the facility failed to ensure education provided to licensed staff was effective. Per the facility's Plan of Correction, for the survey dated 02/11/14, all licensed nurses received education on two (2) occasions on the five (5) rights (right resident, right time, right medication, right dose, and right route) of medication administration. However, a licensed nurse failed to remove a [MEDICATION NAME] prior to the application of a new patch to ensure the resident received the right dose of medication for one (1) of fifteen (15) sampled residents (Resident #15). On 01/14/14, Resident #15 was readmitted to the facility with a [MEDICATION NAME] in place and a physician's orders [REDACTED]. On 01/17/14, the facility applied a [MEDICATION NAME]; however, there was no documented evidence the facility removed the old patch prior to applying the new one. On 01/18/14, Resident #15 was found staring blankly and with minimal response to verbal stimuli. A [MEDICATION NAME] Patch was removed and the resident was sent to the emergency room . Review of hospital documentation revealed a [MEDICATION NAME] Patch was removed in the emergency room also. The resident was administered a dose of [MEDICATION NAME] (Opiate drug reversal drug) 0.4 milligrams (mg) via IV piggyback and the resident woke up and stated his/her name to the emergency room Nurse. Resident #15 was admitted to the Intensive Care Unit (ICU), on 01/19/14 at 12:03 AM, with a primary [DIAGNOSES REDACTED]. The facility's failure to have an effective system to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/03/14 and was determined to exist on 01/17/14. The facility was notified of the Immediate Jeopardy on 04/03/14. An acceptable Allegation of Compliance was received on 04/08/14, alleging the removal of the Immediate Jeopardy on 04/08/14. The State Survey Agency validated, on 04/09/14, the Immediate Jeopardy was removed on 04/08/14, as alleged. The Scope and Severity was lowered to a "D" at 42 CFR 483.20 Resident Assessment F-281; 42 CFR 483.25 Quality of Care F-333; and, 42 CFR 483.75 Administration, F-490 and F-520 while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Executive Director's (ED) job description, revised 04/18/13, revealed the Position Summary as follows: "The ED provides leadership and direction for overall facility operations to provide quality resident care in accordance with all laws and regulations." Further review of the Essential Functions revealed "Must ensure the residents receive high quality care." Review of the Administrative General Policies, (no date), revealed "The ED will be responsible for implementing facility policies and formulating departmental policies with advice and counsel from the consultants, medical staff, and departmental staff. The ED will administer and conduct all aspects of the policies and programs within the framework provided." Review of the facility's Plan of Correction (POC), for the survey dated 02/11/14, revealed all licensed staff was educated on the five (5) rights of medication administration and a post competency test related to medication administration was given on two (2) occasions. The five (5) rights of medication administration are: 1.) Right Resident, 2.) Right Drug, 3.) Right Dose, 4.) Right Time and, 5.) Right Route. However, the facility failed to have an effective system in place to monitor the placement and removal of medication [MEDICATION NAME]es and identify if [MEDICATION NAME]es were in place on admission to ensure the medication was administered at the right dose. Interview and record review revealed Resident #15 was readmitted to the facility, on 01/14/14, with a [MEDICATION NAME] in place. On 01/17/14, the facility applied a [MEDICATION NAME]; however, there was no documented evidence the facility removed the old patch prior to applying the new one. On 01/18/14, Resident #15 was found staring blankly and with minimal response to verbal stimuli and was diagnosed with [REDACTED]. Interview with the Facility's ED, on 04/03/14 at 10:45 AM, revealed she did not initiate an investigation into the incident with Resident #15 because she did not feel there was a medication error made even after she was made aware of hospital documentation that Resident #15 was admitted to the hospital Intensive Care Unit with a [MEDICATION NAME] overdose and had a [MEDICATION NAME] on upon arrival at the hospital. The Executive Director stated the facility received ten (10) [MEDICATION NAME]es from the pharmacy when Resident #1 was admitted . She revealed one (1) patch was administered and one patch was removed prior to the resident going to the hospital. She stated there were nine (9) patches left which meant the count was correct so she did not feel they had made a medication error. However, review of the Hospital Discharge Documentation revealed Resident #15 had a [MEDICATION NAME] applied at the hospital prior to being admitted to the facility. Additionally, she stated, the Medication Administration policy revealed two (2) staff was to monitor the removal and destruction of any used [MEDICATION NAME]es. However, on 01/17/14, there was no documented evidence the staff witnessed the removal and destruction of Resident #15's [MEDICATION NAME] that the resident received at the hospital. Further interview with the ED, on 05/09/14 at 2:00 PM, revealed audits were conducted related to medication administration and the five (5) rights of medication administration, and continue to be ongoing monthly. She stated there was no failure identified related to the facility's policy, which would have led to a second significant medication administration error, nor was there a failure related to the training provided after the first significant medication error. Therefore, she did not feel there was a second significant medication error made. Further interview with the ED revealed 100% of all staff was inserviced related to the five rights of medication administration. The ED reiterated, based on the facility's policy on medication administration, there were no failures identified related to the Admitting Nurse's assessment of Resident #15 on 01/14/14. A Post Survey interview with the Director of Nursing (DON), on 05/20/14 at 1:45 PM, revealed the licensed staff should remove the old [MEDICATION NAME] prior to applying a new patch to ensure the right dose of medication was administered per physician's orders [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/15/14, Resident #15 was discharged home with family and no longer resides at the center. The facility initiated an internal investigation at the time the resident was readmitted on [DATE] and was identified as having an accidental narcotic overdose. The DON, ADON, SDC, and Regional Director of Clinical Services (RDCS) conducted a medication pass audit which included administration, rotation, and patch presence on 02/01/14 and 02/06/14. No discrepancies were identified and the audits were on-going. On 04/07/14, the DON and RDCS completed a validation to ensure that all nine (9) residents with any type of [MEDICATION NAME] had the location of the patch on the resident documented on the MAR and that all medications were being administered per physician's orders [REDACTED]. On 01/24/14, two (2) additional residents were identified as receiving [MEDICATION NAME]es to treat pain. The DON verified the physician's orders [REDACTED]. [MEDICATION NAME]es were audited by the DON on 01/24/14 for all residents with orders to verify the patch count was accurately reflective of the narcotic count sheet. On 04/03/14, the RDCS and the DON reviewed the documentation of the residents with [MEDICATION NAME]es (two residents from 01/23-02/06/14, two (2) residents from 02/06-02/07/14, three (3) residents from 02/07/14-present). The [MEDICATION NAME] orders and January to present MARs reflected the resident's patches were applied per physician's orders [REDACTED]. Residents who had an order for [REDACTED]. The Pharmacist conducted a review of all current [MEDICATION NAME] orders and counts were correct on 02/04/14. She also reviewed the documentation of the location of the patch on the MARs and verified each shift placement check. On 01/31-02/02/14, all licensed nurses were provided education on medication administration including [MEDICATION NAME]es. This education was completed by the DON and the Staff Development Coordinator (SDC) and was provided for 100% of the licensed nurses before midnight on 02/02/14. On 04/03/14, the RDCS completed education for the Executive Director, DON, Assistant Director of Nursing (ADON), SDC, and the Minimum Data Set Coordinator (MDSC) which included: ? [MEDICATION NAME] administration/removal policy and procedure ? Required documentation of the [MEDICATION NAME] removal and application, including anatomical location of patch to be on the MAR. ? Admission documentation in admission assessment/notes to include [MEDICATION NAME]es present and the location. ? Notification of DON or ADON upon receipt of new [MEDICATION NAME] orders received. All licensed nurses received the above training beginning on 04/03/14. Education was completed by the DON, ADON, or MDS Nurse. Education included a quiz which required a score of 100% to validate competency. This education was completed with 100% of licensed staff on 04/04/14. Any licensed nurse who did not receive the above training would not be allowed to work until the training was completed. The DON, ADON, MDS Nurse, and SDC provided education to the Certified Nursing Assistants (CNAs) to include observing for [MEDICATION NAME]es during activity of daily living (ADL) care and to notify the Charge Nurse if more than one (1) patch was identified on the resident. Education was initiated on 04/04/14 and was completed prior to midnight to all staff on duty. Any staff who did not receive the training prior to midnight on 04/04/14 was to receive the training prior to beginning his/her next working shift. Nursing will notify the DON or ADON at the time of all new [MEDICATION NAME] orders received. On 04/03/14, the DON and ADON completed audits of residents' records who were receiving a [MEDICATION NAME] for documentation of placement on the MAR and verified the patch was located on the resident in accordance to the assessed, documented site. The DON, ADON, and RCDS reviewed resident records who currently had [MEDICATION NAME]es to validate the physician's orders [REDACTED]. Beginning 04/04/14, the DON, ADON, SDC, Unit Manager, MDS Nurse and/or RDCS will validate the [MEDICATION NAME]es orders are correct, recorded on the MAR, location will be documented on the MAR, and verify the patch is located on the resident in accordance with the assessed, documented site. The process was to occur seven (7) days a week for thirty (30) days, then would be completed four (4) times a week for thirty (30) days. If a discrepancy was identified, the nurses involved would not be allowed to administer medications until they were retrained and deemed to be competent in medication administration. The DON, ADON, SDC, or Unit Manager will monitor the next five (5) admissions with a [MEDICATION NAME] order beginning on 04/05/14, and again on 04/07/14 to ensure [MEDICATION NAME] orders were recorded on the MAR correctly, the location was documented on the MAR and on the initial data collection tool. They will verify the patch was on the resident as the MAR indicated. If a discrepancy was identified, the nurses involved would not be allowed to administer medications until they were retrained and deemed to be competent in medication administration. All audit and monitoring outcomes would be presented to and reviewed by the Performance Improvement (PI) Committee for revision or plan recommendations. Audits would be completed seven (7) days a week, for the next thirty (30) days, then at a rate of four (4) times per week for thirty (30) days. The PI Committee would meet weekly over the next thirty (30) days, then bi-weekly for thirty (30) days to review results. PI meetings were held on 02/05, 02/06, 02/12, 02/19, 02/26, 03/05, 03/07, 03/09, and 03/19/14. Review of education provided in regard to medication administration as well as full review of completed medication administration audits were conducted at each PI meeting. On 04/03/14, the Medical Director and the resident's attending physician were notified of Immediate Jeopardy and the facility's action plan and both agreed with the action plan. The PI Committee met on 04/04/14 to review the action plan, validate education as completed, and to update the Medical Director on the additional documentation for new admissions on the initial data collection tool and to validate monitoring was in place. The PI Committee consists of the Executive Director, DON, ADON, SDC, MDS Nurse, Social Services, and Activity Director. The PI Committee was to meet weekly for thirty (30) days to review all audits, new admissions with [MEDICATION NAME]es, and revise the care plans to ensure resident's individual needs were met and residents were receiving care to meet the highest practicable well being. The PI Committee was to meet two (2) times a month for thirty (30) days, then monthly to review all audit findings and make revisions as needed to the action plan based on audit findings. **The State Survey Agency validated the corrective action taken by the facility as follows: Record review revealed Resident #15 was discharged home with family on 03/15/14. Review of Medication Pass Audits, dated 02/01/14 and 02/06/14 revealed the DON, ADON, SDC, and RDCS conducted a medication pass audit and monitored the entire medication pass including the administration of medication patches to include ensuring the rotation of sites for the patches, patches were dated and timed, as well as documented on the MAR for placement and removal of the old patch. Random patch audits were ongoing and continued to be performed three (3) times a week. Review of the MAR audit list, dated 04/07/14, revealed the DON and RCDS completed observations of the nine (9) residents with any type of [MEDICATION NAME] to ensure the patch was located at the same site as was documented on the MAR. In addition, they reviewed the physician's orders [REDACTED]. Review of the Physician's Progress Notes, dated 04/03/14, for Resident #10 and Resident #3 revealed both residents were assessed and received [MEDICATION NAME]es with no adverse side effects noted. Review of a Medication Audit form, dated 04/04/14, revealed the pharmacists reviewed the MARs for Resident #3 and Resident #10 for correct documentation for placement, checks, application, removal, and disposal of [MEDICATION NAME]es with no concerns noted. Review of the inservice log, dated 01/31/14-02/02/14, revealed 100% of licensed staff was inserviced and a post test was completed to verify competency of [MEDICATION NAME] administration by the DON and SDC. Review of training, dated 04/03/14, revealed 100% of licensed staff was inserviced on the procedure for Admission/Readmission of residents utilizing [MEDICATION NAME]es by the DON, ADON, SDC, and MDS Coordinator. The training included [MEDICATION NAME] administration and removal policy and procedure; the required documentation of patch removal and application, including location of the patch; the documentation on Admission Assessments and Notes should include if any patches present and the location of the patches; and Notification of the DON and/or ADON upon receipt of new patch orders. A competency exam was given to verify the understanding of the training. 100% of licensed staff was inserviced and new hires will receive the same training. Review of the CNA training log, dated 04/04/14, revealed a phone training was completed by the Regional Nurse Consultant on 04/04/14 which included to observe for patches during care and to utilize a "stop and watch" tool to report areas to the charge nurse. Interviews with RN #2, RN #4, RN #10, RN #11, LPN #1, LPN #5, LPN #6, LPN #7, LPN #8, and LPN #10, on 04/09/14 between 10:15 AM and 10:45 AM, revealed they were trained on the disposal process for [MEDICATION NAME]es, documentation of the site of the patch on the resident, physician notification if more than one (1) patch was found on a resident, and the process of documenting patches on new admissions. Additionally, RN #2, RN #4, RN#10 and RN #11 were educated on the notification of the Director of Nursing and/or the Assistant Director of Nursing of new orders for [MEDICATION NAME]es, the admission process for [MEDICATION NAME]es documentation, placement checking of the patch and to complete a complete body audit if the patch was not where it was supposed to be and conduct an investigation, and the disposal process for the patches which includes two (2) licensed nursing staff to witness and destroy the patch by folding it and placing it in a Sharp's container. Interviews with CNA #1, CNA #2, CNA #3, and CNA #4, on 04/09/14 between 10:15 AM and 10:45 AM, revealed they were inserviced on reporting to the Charge Nurse if while performing care to a resident, two (2) patches were found to be present on the resident. They stated they would fill out a "Stop and Watch" form and turn it in to the Charge Nurse. Review of the [MEDICATION NAME] Patch Audits, on 04/08/14 and 04/09/14 revealed all new [MEDICATION NAME] orders were reported to the DON and/or ADON. The DON and ADON completed audits of residents who were currently on a [MEDICATION NAME] of any kind with the last audit completed on 04/08/14 and to continue every day for seven (7) days. The facility did not have any new admissions on [MEDICATION NAME]es at this time. On 04/03/14, the Medical Director was notified of the AoC and agreed with the plan with a verified signature. Review of the Quality Assurance meeting notes, dated 01/01/14, revealed the AoC was discussed via a phone call between the Medical Director and the Executive Director. Review of the PI Committee meeting documentation, dated 01/01/14 through 03/19/14 revealed meetings were held weekly to review all audits, new admissions with [MEDICATION NAME]es, and revise the care plans to ensure resident's individual needs were met and residents were receiving care to meet the highest practicable well being. Interviews conducted with the ADON, DON, and the Executive Director, on 04/09/14, revealed medication administration was discussed in the PI meetings as stated in the AoC and training was provided to licensed nursing staff as well as the CNAs related to identifying multiple patches on residents or a patch on a resident on initial admission to the facility.

Based on observation, interview, record review, and review of the facility's policy and procedures, facility investigation, hospital History and Physical, hospital Discharge Summary, hospital Medication Administration Record (MAR) and hospital Laboratory Report it was determined the facility failed to have an effective system in place to monitor the placement and removal of medication [MEDICATION NAME]es and identify if [MEDICATION NAME]es were in place on admission to ensure one (1) of fifteen (15) sampled residents (Resident #15) was free from a significant medication error. The five (5) rights of medication administration 1.) Right Resident, 2.) Right Drug, 3.) Right Dose, 4.) Right Time and, 5.) Right Route were listed in the facility's 02/11/14, Plan of Correction. Further review revealed all licensed staff was educated on the five (5) rights of medication administration and a post competency test related to medication administration was given on two (2) occasions. However, the facility failed to have an effective system to ensure staff administered medications according to the five rights and monitored the placement and removal of medication [MEDICATION NAME]es; and, identified if [MEDICATION NAME]es were in place on admission to ensure the medication was administered at the right dose. On 01/14/14, Resident #15 was readmitted to the facility from the hospital with a physician's orders [REDACTED]. Review of the hospital Medication Administration Record (MAR) revealed a [MEDICATION NAME] 50 microgram (mcg) patch was placed on the resident that morning. There was no documented evidence the facility had identified Resident #15 had a [MEDICATION NAME] on when he/she arrived at the facility. On 01/17/14, the facility's licensed staff applied a [MEDICATION NAME] 50 mcg patch to the resident. However, there was no documented evidence the [MEDICATION NAME] that was applied at the hospital had been removed. On 01/18/14 at approximately 5:15 PM, the resident was found staring blankly with minimal response to verbal stimuli. The physician was called and instructions were received to remove the [MEDICATION NAME] Patch and send the resident to the emergency room for evaluation. The [MEDICATION NAME] Patch was removed and the resident was sent to the emergency room . Hospital documentation revealed another [MEDICATION NAME] was removed from the resident at the hospital. The resident was administered a dose of [MEDICATION NAME] (Opiate drug reversal drug) 0.4 milligrams (mg) via intravenous (IV) piggyback, and the resident aroused and was able to state his/her name to the nurse. Resident #15 was admitted to the Intensive Care Unit (ICU) on 01/19/14 at 12:03 AM with a primary [DIAGNOSES REDACTED]. The facility's failure to ensure the resident was free from a significant medication error has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/03/14 and was determined to exist on 01/17/14. The facility was notified of the Immediate Jeopardy on 04/03/14. An acceptable Allegation of Compliance was received on 04/08/14, alleging the removal of the Immediate Jeopardy on 04/08/14. The State Survey Agency validated, on 04/09/14, the Immediate Jeopardy was removed on 04/08/14, as alleged. The Scope and Severity was lowered to a "D" at 42 CFR 483.20 Resident Assessment F-281; 42 CFR 483.25 Quality of Care F-333; and, 483.75 Administration, F-490 and F-520 while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Policy and Procedure titled, "Administration of Medication", last revised October 2004, revealed a standard, "All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnoses. It is the responsibility of the nursing professional to be aware of the classification, action, correct dosage, route, frequency, duration, and other required considerations for administration of medication. Review of the facility's Disposal of [MEDICATION NAME] Patches policy, last revised 10/2010, revealed the facility should have the disposal of a [MEDICATION NAME] witnessed by another nurse to prevent diversion. Document the removal and disposal of the patch. Record review revealed the facility admitted Resident #15 on 01/14/14 with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) Assessment, dated 01/30/14, revealed the facility assessed Resident #15's cognition as intact with a Brief Interview Mental Status (BIMS) score of fifteen (15). Interview with Registered Nurse (RN) #8, on 03/26/14 at 10:22 AM, revealed he was the Admission Nurse on 01/14/14, when Resident #15 was admitted to the nursing facility. He stated he completed a head to toe skin assessment of the resident to identify if the resident had any skin issues. He stated he could not remember if the resident had a [MEDICATION NAME] Patch in place and if he had identified a [MEDICATION NAME] was on the resident he would not have noted it, as he was assessing for skin issues. Review of Resident #15's hospital January 2014 Medication Administration Record (MAR) revealed on 01/14/14 the resident was administered a fifty (50) mcg [MEDICATION NAME] Patch at 8:32 AM, prior to the resident being discharged to the nursing facility. However, review of the "Initial Data Collection Tool/Nursing Service" which included a skin assessment, dated 01/14/14 at 9:20 PM, and review of the facility's January 2014 MAR revealed there was no documentation of Resident #15 having a [MEDICATION NAME] Patch in place on admission. Review of the facility's admission orders [REDACTED]. Review of Resident #15's January 2014 MAR revealed the facility applied a [MEDICATION NAME] 50 mcg Patch on 01/17/14; however, further review of the MAR and the resident's record revealed there was no documented evidence of a patch being removed or disposal of the patch. Review of Nurse's Notes, dated 01/18/14 at 5:15 PM, revealed Resident #15 was found staring blankly with minimal response to verbal stimuli. The physician was notified and instructions were received to remove the resident's [MEDICATION NAME] Patch and send the resident to the emergency room for evaluation. Review of the Nursing Home to Hospital Transfer Form, dated 01/18/14 at 6:40 PM, revealed a [MEDICATION NAME] Patch was removed prior to sending the resident to the emergency room . Interview with Registered Nurse (RN) #1, on 03/26/14 at 6:10 PM, revealed when she assessed Resident #15 he/she was breathing with shallow breaths and was lethargic. RN #1 stated she asked Licensed Practical Nurse (LPN) #4, who was in the room, to remove the [MEDICATION NAME] Patch from Resident #15 per physician's instructions. RN #1 revealed she had assessed Resident #15 earlier in the day and the resident's oxygen saturation was not reading as it should have been and she applied oxygen. She stated she did not perform a head to toe assessment on the resident prior to sending him/her to the emergency room because she felt the resident had a stroke and wanted to get him/her sent out as soon as possible. Additionally, she revealed to her knowledge the resident had only one (1) patch applied. Interview with LPN #4, on 03/26/14 at 6:27 PM, revealed she was in Resident #15's room with RN #1 and LPN #1. She stated RN #1 asked her to remove a [MEDICATION NAME] Patch from the resident because he/she had become lethargic. She stated she removed the patch from the right side of the chest and did not see any other patches on the resident. Interview with LPN #1, on 03/28/14 at 10:17 AM, revealed she was in Resident #15's room with RN #1 and LPN #4 and they stated the resident was unresponsive. RN #1 asked LPN #4 to remove a [MEDICATION NAME] Patch. Additionally, she stated the resident was rolled several times in the process of getting him/her ready for discharge and she did not notice another patch on the resident. Review of the Hospital History and Physical from the Intensive Care Unit, dated 01/18/14, revealed the resident was admitted with a chief complaint of Acute Altered Mental Status and was responding only to painful stimuli. The resident was not verbally responsive at the time of admission. All of the resident's pain medication was discontinued and the response was monitored. Review of the Hospital Discharge Summary, dated 01/23/14, revealed Resident #15 was brought to the emergency roiagnom on [DATE] for confusion and was found to have a [MEDICATION NAME] Patch and it was removed at the hospital. The resident was given [MEDICATION NAME] and immediately started to arouse and was able to tell the nurse his/her name. Review of a hospital Laboratory Report, dated 01/18/14, revealed a urine drug screen was completed and the urine tested negative for Opiates. Interview with the Hospital Pharmacist Manager, on 04/02/14 at 11:10 AM, revealed if a [MEDICATION NAME] Patch was left in place and another applied the resident would not be at a full dose but would be receiving between fifty (50) and one hundred (100) mcg related to [MEDICATION NAME] being a residual drug. Additionally, she stated a urine test for opiate detection could show negative results even if the resident had an excess amount of the drug in the system because [MEDICATION NAME] was a synthetic drug and would not show up in a urine drug test. Interview with the Intensive Care Unit RN #7, on 04/02/14 at 11:22 AM, revealed he was the Admission Nurse on 01/19/14, when Resident #15 was admitted to the Intensive Care Unit from the emergency room . He stated his documentation revealed he was informed the resident had a [MEDICATION NAME] Patch removed in the emergency room , but he could not specifically remember being told. Review of the facility's investigation, (no date), revealed on 01/18/14 (no time), Resident #15 had decreased level of consciousness and nursing staff removed a [MEDICATION NAME] Patch, applied oxygen, and performed an accu-check (test blood sugar level). The resident was discharged to the emergency roiagnom on [DATE] (no time) and was admitted to the hospital on [DATE]. The Discharge Summary from the emergency room to the Intensive Care Unit revealed emergency room staff removed a [MEDICATION NAME] Patch and administered [MEDICATION NAME]. In addition, review of interviews conducted by the facility's Administration, on 01/23/14, revealed RN #1 stated a verbal report received from the hospital nursing staff on 01/23/14 to LPN #1, prior to Resident #15 returning to the facility, revealed the resident had a [MEDICATION NAME] Patch in place on admission to the hospital. Interview with the Director of Nursing (DON), on 03/28/14 at 3:00 PM, revealed nursing staff should perform a head to toe assessment on new admissions and when a resident was sent out to the hospital an assessment should be completed related to the issue of concern. The DON stated she would expect the nursing staff to know if a resident had a patch on and would expect them to document it in the Nurse's Notes, or on the MAR. Interview with the facility's Medical Director, on 03/28/14 at 3:15 PM, revealed he would have expected nursing staff to look at all of the resident's medications on admission and if the list included a [MEDICATION NAME] Patch, he would have expected the nurse to assess the resident to see if the patch was administered in the hospital prior to coming to the nursing home. Additionally, he stated he could not say whether or not the dose of [MEDICATION NAME] the resident had received was life threatening as he did not assess the resident. Interview with the facility's Executive Director, on 04/03/14 at 10:45 AM, revealed she did not initiate an investigation because she did not feel there was a medication error made even after she was aware of Resident #15 being admitted to the hospital Intensive Care Unit with a [MEDICATION NAME] overdose. The Executive Director stated the facility received ten (10) [MEDICATION NAME]es from the pharmacy when the Resident #15 was admitted . She revealed one (1) patch was administered to the resident and one patch was removed from the resident prior to the resident going to the hospital. She stated there were nine (9) patches left which meant the count was correct so she did not feel they had made a medication error. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/15/14, Resident #15 was discharged home with family and no longer resides at the center. The facility initiated an internal investigation at the time the resident was readmitted on [DATE] and was identified as having an accidental narcotic overdose. The DON, ADON, SDC, and Regional Director of Clinical Services (RDCS) conducted a medication pass audit which included administration, rotation, and patch presence on 02/01/14 and 02/06/14. No discrepancies were identified and the audits were on-going. On 04/07/14, the DON and RDCS completed a validation to ensure that all nine (9) residents with any type of [MEDICATION NAME] had the location of the patch on the resident documented on the MAR and that all medications were being administered per physician's orders [REDACTED]. On 01/24/14, two (2) additional residents were identified as receiving [MEDICATION NAME]es to treat pain. The DON verified the physician's orders [REDACTED]. [MEDICATION NAME]es were audited by the DON on 01/24/14 for all residents with orders to verify the patch count was accurately reflective of the narcotic count sheet. On 04/03/14, the RDCS and the DON reviewed the documentation of the residents with [MEDICATION NAME]es (two residents from 01/23-02/06/14, two (2) residents from 02/06-02/07/14, three (3) residents from 02/07/14-present). The [MEDICATION NAME] orders and January to present MARs reflected the resident's patches were applied per physician's orders [REDACTED]. Residents who had an order for [REDACTED]. The Pharmacist conducted a review of all current [MEDICATION NAME] orders and counts were correct on 02/04/14. She also reviewed the documentation of the location of the patch on the MARs and verified each shift placement check. On 01/31-02/02/14, all licensed nurses were provided education on medication administration including [MEDICATION NAME]es. This education was completed by the DON and the Staff Development Coordinator (SDC) and was provided for 100% of the licensed nurses before midnight on 02/02/14. On 04/03/14, the RDCS completed education for the Executive Director, DON, Assistant Director of Nursing (ADON), SDC, and the Minimum Data Set Coordinator (MDSC) which included: ? [MEDICATION NAME] administration/removal policy and procedure ? Required documentation of the [MEDICATION NAME] removal and application, including anatomical location of patch to be on the MAR. ? Admission documentation in admission assessment/notes to include [MEDICATION NAME]es present and the location. ? Notification of DON or ADON upon receipt of new [MEDICATION NAME] orders received. ? All licensed nurses received the above training beginning on 04/03/14. Education was completed by the DON, ADON, or MDS Nurse. Education included a quiz which required a score of 100% to validate competency. This education was completed with 100% of licensed staff on 04/04/14. Any licensed nurse who did not receive the above training would not be allowed to work until the training was completed. The DON, ADON, MDS Nurse, and SDC provided education to the Certified Nursing Assistants (CNAs) to include observing for [MEDICATION NAME]es during activity of daily living (ADL) care and to notify the Charge Nurse if more than one (1) patch was identified on the resident. Education was initiated on 04/04/14 and was completed prior to midnight to all staff on duty. Any staff who did not receive the training prior to midnight on 04/04/14 was to receive the training prior to beginning his/her next working shift. Nursing will notify the DON or ADON at the time of all new [MEDICATION NAME] orders received. On 04/03/14, the DON and ADON completed audits of residents' records who were receiving a [MEDICATION NAME] for documentation of placement on the MAR and verified the patch was located on the resident in accordance to the assessed, documented site. The DON, ADON, and RCDS reviewed resident records who currently had [MEDICATION NAME]es to validate the physician's orders [REDACTED]. Beginning 04/04/14, the DON, ADON, SDC, Unit Manager, MDS Nurse and/or RDCS will validate the [MEDICATION NAME]es orders are correct, recorded on the MAR, location will be documented on the MAR, and verify the patch is located on the resident in accordance with the assessed, documented site. The process was to occur seven (7) days a week for thirty (30) days, then would be completed four (4) times a week for thirty (30) days. If a discrepancy was identified, the nurses involved would not be allowed to administer medications until they were retrained and deemed to be competent in medication administration. The DON, ADON, SDC, or Unit Manager will monitor the next five (5) admissions with a [MEDICATION NAME] order beginning on 04/05/14, and again on 04/07/14 to ensure [MEDICATION NAME] orders were recorded on the MAR correctly, the location was documented on the MAR and on the initial data collection tool. They will verify the patch was on the resident as the MAR indicated. If a discrepancy was identified, the nurses involved would not be allowed to administer medications until they were retrained and deemed to be competent in medication administration. All audit and monitoring outcomes would be presented to and reviewed by the Performance Improvement (PI) Committee for revision or plan recommendations. Audits would be completed seven (7) days a week, for the next thirty (30) days, then at a rate of four (4) times per week for thirty (30) days. The PI Committee would meet weekly over the next thirty (30) days, then bi-weekly for thirty (30) days to review results. PI meetings were held on 02/05, 02/06, 02/12, 02/19, 02/26, 03/05, 03/07, 03/09, and 03/19/14. Review of education provided in regard to medication administration as well as full review of completed medication administration audits were conducted at each PI meeting. On 04/03/14, the Medical Director and the resident's attending physician were notified of Immediate Jeopardy and the facility's action plan and both agreed with the action plan. The PI Committee met on 04/04/14 to review the action plan, validate education as completed, and to update the Medical Director on the additional documentation for new admissions on the initial data collection tool and to validate monitoring was in place. The PI Committee consists of the Executive Director, DON, ADON, SDC, MDS Nurse, Social Services, and Activity Director. The PI Committee was to meet weekly for thirty (30) days to review all audits, new admissions with [MEDICATION NAME]es, and revise the care plans to ensure resident's individual needs were met and residents were receiving care to meet the highest practicable well being. The PI Committee was to meet two (2) times a month for thirty (30) days, then monthly to review all audit findings and make revisions as needed to the action plan based on audit findings. **The State Survey Agency validated the corrective action taken by the facility as follows: Record review revealed Resident #15 was discharged home with family on 03/15/14. Review of Medication Pass Audits, dated 02/01/14 and 02/06/14 revealed the DON, ADON, SDC, and RDCS conducted a medication pass audit and monitored the entire medication pass including the administration of medication patches to include ensuring the rotation of sites for the patches, patches were dated and timed, as well as documented on the MAR for placement and removal of the old patch. Random patch audits were ongoing and continued to be performed three (3) times a week. Review of the MAR audit list, dated 04/07/14, revealed the DON and RCDS completed observations of the nine (9) residents with any type of [MEDICATION NAME] to ensure the patch was located at the same site as was documented on the MAR. In addition, they reviewed the physician's orders [REDACTED]. Review of the Physician's Progress Notes, dated 04/03/14, for Resident #10 and Resident #3 revealed both residents were assessed and received [MEDICATION NAME]es with no adverse side effects noted. Review of a Medication Audit form, dated 04/04/14, revealed the pharmacists reviewed the MARs for Resident #3 and Resident #10 for correct documentation for placement, checks, application, removal, and disposal of [MEDICATION NAME]es with no concerns noted. Review of the inservice log, dated 01/31/14-02/02/14, revealed 100% of licensed staff was inserviced and a post test was completed to verify competency of [MEDICATION NAME] administration by the DON and SDC. Review of training, dated 04/03/14, revealed 100% of licensed staff to include RN #8 was inserviced on the procedure for Admission/Readmission of residents utilizing [MEDICATION NAME]es by the DON, ADON, SDC, and MDS Coordinator. The training included [MEDICATION NAME] administration and removal policy and procedure; the required documentation of patch removal and application, including location of the patch; the documentation on Admission Assessments and Notes should include if any patches present and the location of the patches; and Notification of the DON and/or ADON upon receipt of new patch orders. A competency exam was given to verify the understanding of the training. 100% of licensed staff was inserviced and new hires will receive the same training. Review of the CNA training log, dated 04/04/14, revealed a phone training was completed by the Regional Nurse Consultant on 04/04/14 which included to observe for patches during care and to utilize a "stop and watch" tool to report areas to the charge nurse. Interviews with RN #2, RN #4, RN #10, RN #11, LPN #1, LPN #5, LPN #6, LPN #7, LPN #8, and LPN #10, on 04/09/14 between 10:15 AM and 10:45 AM, revealed they were trained on the disposal process for [MEDICATION NAME]es, documentation of the site of the patch on the resident, physician notification if more than one (1) patch was found on a resident, and the process of documenting patches on new admissions. Additionally, RN #2, RN #4, RN#10 and RN #11 were educated on the notification of the Director of Nursing and/or the Assistant Director of Nursing of new orders for [MEDICATION NAME]es, the admission process for [MEDICATION NAME]es documentation, placement checking of the patch and to complete a complete body audit if the patch was not where it was supposed to be and conduct an investigation, and the disposal process for the patches which includes two (2) licensed nursing staff to witness and destroy the patch by folding it and placing it in a Sharp's container. Interviews with CNA #1, CNA #2, CNA #3, and CNA #4, on 04/09/14 between 10:15 AM and 10:45 AM, revealed they were inserviced on reporting to the Charge Nurse if while performing care to a resident, two (2) patches were found to be present on the resident. They stated they would fill out a "Stop and Watch" form and turn it in to the Charge Nurse. Review of the [MEDICATION NAME] Patch Audits, on 04/08/14 and 04/09/14 revealed all new [MEDICATION NAME] orders were reported to the DON and/or ADON. The DON and ADON completed audits of residents who were currently on a [MEDICATION NAME] of any kind with the last audit completed on 04/08/14 and to continue every day for seven (7) days. The facility did not have any new admissions on [MEDICATION NAME]es at this time. On 04/03/14, the Medical Director was notified of the AoC and agreed with the plan with a verified signature. Review of the Quality Assurance meeting notes, dated 01/01/14, revealed the AoC was discussed via a phone call between the Medical Director and the Executive Director. Review of the PI Committee meeting documentation, dated 01/01/14 through 03/19/14 revealed meetings were held weekly to review all audits, new admissions with [MEDICATION NAME]es, and revise the care plans to ensure resident's individual needs were met and residents were receiving care to meet the highest practicable well being. Interviews conducted with the ADON, DON, and the Executive Director, on 04/09/14, revealed medication administration was discussed in the PI meetings as stated in the AoC and training was provided to licensed nursing staff as well as the CNAs related to identifying multiple patches on residents or a patch on a resident on initial admission to the facility.

Based on observation, interview, record review, and review of the facility's policy and procedures, the hospital History and Physical, hospital Discharge Summary and the hospital's January 2014 Medication Administration Record (MAR), it was determined the facility failed to administer medication in accordance with acceptable standards of practice for one (1) of fifteen (15) sampled residents (Resident #15). The facility failed to have an effective system in place to monitor the placement and removal of medication [MEDICATION NAME]es and identify if [MEDICATION NAME]es were in place on admission to ensure the medication was administered at the right dose. Review of the facility's Plan of Correction (POC), for the survey dated 02/11/14, revealed all licensed staff was educated on the five (5) rights of medication administration and a post competency test related to medication administration was given on two (2) occasions. The five (5) rights of medication administration are: 1.) Right Resident, 2.) Right Drug, 3.) Right Dose, 4.) Right Time and, 5.) Right Route. However, the facility failed to have an effective system in place to ensure staff followed standards of practice related to medication administration. The facility failed to ensure staff monitored the placement and removal of medication [MEDICATION NAME]es and identified if [MEDICATION NAME]es were in place on admission to ensure the medication was administered at the right dose. On 01/14/14, Resident #15 was readmitted to the facility with a physician's orders [REDACTED]. The hospital had applied the [MEDICATION NAME] that morning prior to the resident's transfer to the facility. On 01/17/14, the facility applied a [MEDICATION NAME]; however, there was no documented evidence the facility had identified that the [MEDICATION NAME] that was applied at the hospital was in place on admission, or that the patch had been removed on or before applying another patch. On 01/18/14 at approximately 5:15 PM, Resident #15 was found staring blankly, with minimal response to verbal stimuli. The physician was notified and a fifty (50) microgram (mcg) [MEDICATION NAME] Patch was removed from the resident's chest at the facility. The resident was sent to the emergency room for evaluation. Review of hospital documentation revealed a [MEDICATION NAME] Patch was removed in the emergency room . The resident was administered a dose of [MEDICATION NAME] (Opiate drug reversal drug) 0.4 milligrams (mg) via IV piggyback and the resident woke up and stated his/her name to the emergency room Nurse. Resident #15 was admitted to the Intensive Care Unit (ICU), on 01/19/14 at 12:03 AM, with a primary [DIAGNOSES REDACTED]. The facility's failure to ensure medication was administered at the right dose according to nursing standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/03/14 and was determined to exist on 01/17/14. The facility was notified of the Immediate Jeopardy on 04/03/14. An acceptable Allegation of Compliance was received on 04/08/14, alleging the removal of the Immediate Jeopardy on 04/08/14. The State Survey Agency validated, on 04/09/14, the Immediate Jeopardy was removed on 04/08/14, as alleged. The Scope and Severity was lowered to a "D" at 42 CFR 483.20 Resident Assessment F-281; 42 CFR 483.25 Quality of Care F-333; and, 483.75 Administration, F-490 and F-520 while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Kentucky Board of Nursing Advisory Opinion Statement (AOS) #14 Patient Care Orders, revised 10/2010, revealed Registered Nurses and Licensed Practical Nurses are responsible for the administration of medication or treatment as authorized by a Physician, Physician Assistant, or Advanced Practice Registered Nurse. Components of medication administration include but are not limited to preparing and giving medication in the prescribed dose, route, and frequency. Review of the facility's Disposal of [MEDICATION NAME] Patches policy, last revised 10/2010, revealed the facility should have the disposal of a [MEDICATION NAME] witnessed by another nurse to prevent diversion. Document the removal and disposal of the patch. Record review revealed the facility admitted Resident #15 on 01/14/14 with [DIAGNOSES REDACTED]. Review of Resident #15's hospital January 2014 MAR revealed, on 01/14/14, the resident was administered a fifty (50) mcg [MEDICATION NAME] Patch at 8:32 AM, at the hospital. However, review of the resident's "Initial Data Collection Tool/Nursing Service" form which included a skin assessment, Nurse's Notes, dated 01/14/14, and the facility's January 2014 MAR revealed there was no documented evidence the facility had identified Resident #15 was admitted with a [MEDICATION NAME] Patch in place. Interview with Registered Nurse (RN) #8, on 03/26/14 at 10:22 AM, revealed he was the Admission Nurse on 01/14/14, when Resident #15 was admitted to the nursing facility. He stated he completed a head to toe skin assessment on the resident but could not remember whether or not the resident had a [MEDICATION NAME] Patch on admission. He revealed if he had identified a patch was in place it would not have been noteworthy as he was observing for skin issues. Review of Resident #15's admission orders [REDACTED]. Further review of the January 2014 MAR revealed a [MEDICATION NAME] was applied to the resident at the facility on 01/17/14; however, there was no documented evidence a [MEDICATION NAME] Patch was removed on, or before 01/17/14 to ensure an accurate dose of medication was administered. Review of Nurse's Notes, dated 01/18/14 at 5:15 PM, revealed Resident #15 was staring blankly with minimal response to verbal stimuli. The physician was notified and instructions were received to remove the [MEDICATION NAME] Patch and send the resident to the emergency room for evaluation. Review of the Nursing Home to Hospital Transfer Form, dated 01/18/14 at 6:40 PM, revealed a [MEDICATION NAME] Patch was removed prior to sending the resident to the emergency room . Interview with RN #1, on 03/26/14 at 6:10 PM, revealed when she assessed Resident #15, the resident's respirations were shallow and the resident was lethargic. The RN stated she directed Licensed Practical Nurse (LPN) #4 to remove the resident's [MEDICATION NAME] Patch. RN #1 stated to her knowledge the resident had only had one (1) [MEDICATION NAME] Patch . Interview with LPN #4, on 03/26/14 at 6:27 PM, revealed she was in Resident #15's room and was asked by RN #1 to remove a [MEDICATION NAME] Patch from the resident because he/she had become lethargic. She stated she removed the patch from the right side of the chest and did not see any other patches on the resident. Interview with LPN #1, on 03/28/14 at 10:17 AM, revealed she was in Resident #15's room and RN #1 stated the resident was unresponsive and asked LPN #4 to remove a [MEDICATION NAME] Patch. LPN #1 stated the resident was rolled several times in the process of getting him/her ready for discharge and she did not notice another patch on the resident. Review of the Hospital Discharge Summary, dated 01/23/14, revealed Resident #15 was brought to the emergency room for confusion and a [MEDICATION NAME] Patch was found on the resident; the patch was removed at the hospital. The resident was given [MEDICATION NAME] and immediately started to arouse and was able to tell the nurse his/her name. Interview with RN #7, on 04/02/14 at 11:22 AM, revealed he was the Admission Nurse on 01/19/14, when Resident #15 was admitted to the Intensive Care Unit from the emergency room . He stated his documentation from 01/19/14 indicated he had been informed the resident had a [MEDICATION NAME] Patch removed in the emergency room . Interview with the Hospital Pharmacist Manager, on 04/02/14 at 11:10 AM, revealed if a [MEDICATION NAME] Patch was left in place and another applied the resident would not be at a full dose but would be receiving between fifty (50) and one hundred (100) mcg related to [MEDICATION NAME] being a residual drug. Interview with the Director of Nursing (DON), on 03/28/14 at 3:00 PM, revealed nursing staff perform a head to toe assessment on new admissions and she would expect the nursing staff to know if a resident had a patch on and would expect them to document it in the Nursing Notes or on the MAR. Interview with the facility's Medical Director, on 03/28/14 at 3:15 PM, revealed he would have expected nursing staff to look at all of the resident's medications and if the list included a [MEDICATION NAME] Patch, he would have expected the nurse to assess the resident to see if the patch was administered in the hospital prior to coming to the nursing home. Additionally, he stated he could not say whether or not the dose of [MEDICATION NAME] the resident had was life threatening as he did not assess him/her. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/15/14, Resident #15 was discharged home with family and no longer resides at the center. The facility initiated an internal investigation at the time the resident was readmitted on [DATE] and was identified as having an accidental narcotic overdose. The DON, ADON, SDC, and Regional Director of Clinical Services (RDCS) conducted a medication pass audit which included administration, rotation, and patch presence on 02/01/14 and 02/06/14. No discrepancies were identified and the audits were on-going. On 04/07/14, the DON and RDCS completed a validation to ensure that all nine (9) residents with any type of [MEDICATION NAME] had the location of the patch on the resident documented on the MAR and that all medications were being administered per physician's orders [REDACTED]. On 01/24/14, two (2) additional residents were identified as receiving [MEDICATION NAME]es to treat pain. The DON verified the physician's orders [REDACTED]. [MEDICATION NAME]es were audited by the DON on 01/24/14 for all residents with orders to verify the patch count was accurately reflective of the narcotic count sheet. On 04/03/14, the RDCS and the DON reviewed the documentation of the residents with [MEDICATION NAME]es (two residents from 01/23-02/06/14, two (2) residents from 02/06-02/07/14, three (3) residents from 02/07/14-present). The [MEDICATION NAME] orders and January to present MARs reflected the resident's patches were applied per physician's orders [REDACTED]. Residents who had an order for [REDACTED]. The Pharmacist conducted a review of all current [MEDICATION NAME] orders and counts were correct on 02/04/14. She also reviewed the documentation of the location of the patch on the MARs and verified each shift placement check. On 01/31-02/02/14, all licensed nurses were provided education on medication administration including [MEDICATION NAME]es. This education was completed by the DON and the Staff Development Coordinator (SDC) and was provided for 100% of the licensed nurses before midnight on 02/02/14. On 04/03/14, the RDCS completed education for the Executive Director, DON, Assistant Director of Nursing (ADON), SDC, and the Minimum Data Set Coordinator (MDSC) which included: ? [MEDICATION NAME] administration/removal policy and procedure; ? Required documentation of the [MEDICATION NAME] removal and application, including anatomical location of patch to be on the MAR; ? Admission documentation in admission assessment/notes to include [MEDICATION NAME]es present and the location; ? Notification of DON or ADON upon receipt of new [MEDICATION NAME] orders received. All licensed nurses received the above training beginning on 04/03/14. Education was completed by the DON, ADON, or MDS Nurse. Education included a quiz which required a score of 100% to validate competency. This education was completed with 100% of licensed staff on 04/04/14. Any licensed nurse who did not receive the above training would not be allowed to work until the training was completed. The DON, ADON, MDS Nurse, and SDC provided education to the Certified Nursing Assistants (CNAs) to include observing for [MEDICATION NAME]es during activity of daily living (ADL) care and to notify the Charge Nurse if more than one (1) patch was identified on the resident. Education was initiated on 04/04/14 and was completed prior to midnight to all staff on duty. Any staff who did not receive the training prior to midnight on 04/04/14 was to receive the training prior to beginning his/her next working shift. Nursing will notify the DON or ADON at the time of all new [MEDICATION NAME] orders received. On 04/03/14, the DON and ADON completed audits of residents' records who were receiving a [MEDICATION NAME] for documentation of placement on the MAR and verified the patch was located on the resident in accordance to the assessed, documented site. The DON, ADON, and RCDS reviewed resident records who currently had [MEDICATION NAME]es to validate the physician's orders [REDACTED]. Beginning 04/04/14, the DON, ADON, SDC, Unit Manager, MDS Nurse and/or RDCS will validate the [MEDICATION NAME]es orders are correct, recorded on the MAR, location will be documented on the MAR, and verify the patch is located on the resident in accordance with the assessed, documented site. The process was to occur seven (7) days a week for thirty (30) days, then would be completed four (4) times a week for thirty (30) days. If a discrepancy was identified, the nurses involved would not be allowed to administer medications until they were retrained and deemed to be competent in medication administration. The DON, ADON, SDC, or Unit Manager will monitor the next five (5) admissions with a [MEDICATION NAME] order beginning on 04/05/14, and again on 04/07/14 to ensure [MEDICATION NAME] orders were recorded on the MAR correctly, the location was documented on the MAR and on the initial data collection tool. They will verify the patch was on the resident as the MAR indicated. If a discrepancy was identified, the nurses involved would not be allowed to administer medications until they were retrained and deemed to be competent in medication administration. All audit and monitoring outcomes would be presented to and reviewed by the Performance Improvement (PI) Committee for revision or plan recommendations. Audits would be completed seven (7) days a week, for the next thirty (30) days, then at a rate of four (4) times per week for thirty (30) days. The PI Committee would meet weekly over the next thirty (30) days, then bi-weekly for thirty (30) days to review results. PI meetings were held on 02/05, 02/06, 02/12, 02/19, 02/26, 03/05, 03/07, 03/09, and 03/19/14. Review of education provided in regard to medication administration as well as full review of completed medication administration audits were conducted at each PI meeting. On 04/03/14, the Medical Director and the resident's attending physician were notified of Immediate Jeopardy and the facility's action plan and both agreed with the action plan. The PI Committee met on 04/04/14 to review the action plan, validate education as completed, and to update the Medical Director on the additional documentation for new admissions on the initial data collection tool and to validate monitoring was in place. The PI Committee consists of the Executive Director, DON, ADON, SDC, MDS Nurse, Social Services, and Activity Director. The PI Committee was to meet weekly for thirty (30) days to review all audits, new admissions with [MEDICATION NAME]es, and revise the care plans to ensure resident's individual needs were met and residents were receiving care to meet the highest practicable well being. The PI Committee was to meet two (2) times a month for thirty (30) days, then monthly to review all audit findings and make revisions as needed to the action plan based on audit findings. **The State Survey Agency validated the corrective action taken by the facility as follows: Record review revealed Resident #15 was discharged home with family on 03/15/14. Review of Medication Pass Audits, dated 02/01/14 and 02/06/14 revealed the DON, ADON, SDC, and RDCS conducted a medication pass audit and monitored the entire medication pass including the administration of medication patches to include ensuring the rotation of sites for the patches, patches were dated and timed, as well as documented on the MAR for placement and removal of the old patch. Random patch audits were ongoing and continued to be performed three (3) times a week. Review of the MAR audit list, dated 04/07/14, revealed the DON and RCDS completed observations of the nine (9) residents with any type of [MEDICATION NAME] to ensure the patch was located at the same site as was documented on the MAR. In addition, they reviewed the physician's orders [REDACTED]. Review of the Physician's Progress Notes, dated 04/03/14, for Resident #10 and Resident #3 revealed both residents were assessed and received [MEDICATION NAME]es with no adverse side effects noted. Review of a Medication Audit form, dated 04/04/14, revealed the pharmacists reviewed the MARs for Resident #3 and Resident #10 for correct documentation for placement, checks, application, removal, and disposal of [MEDICATION NAME]es with no concerns noted. Review of the inservice log, dated 01/31/14-02/02/14, revealed 100% of licensed staff was inserviced, by the DON and SDC, and a post test was completed to verify competency of [MEDICATION NAME] administration. Review of training, dated 04/03/14, revealed 100% of licensed staff was inserviced by the DON, ADON, SDC, and MDS Coordinator, on the procedure for Admission/Readmission of residents utilizing [MEDICATION NAME]es. The training included [MEDICATION NAME] administration and removal policy and procedure; the required documentation of patch removal and application, including location of the patch; the documentation on Admission Assessments and Notes should include if any patches were present and the location of the patches; and Notification of the DON and/or ADON upon receipt of new patch orders. A competency exam was given to verify the understanding of the training. 100% of licensed staff was inserviced and new hires will receive the same training. Review of the CNA training log, dated 04/04/14, revealed a phone training was completed by the Regional Nurse Consultant on 04/04/14 which included to observe for patches during care and to utilize a "stop and watch" tool to report areas to the Charge Nurse. Interviews with RN #2, RN #4, RN #10, RN #11, LPN #1, LPN #5, LPN #6, LPN #7, LPN #8, and LPN #10, on 04/09/14 between 10:15 AM and 10:45 AM, revealed they were trained on the disposal process for [MEDICATION NAME]es, documentation of the site of the patch on the resident, physician notification if more than one (1) patch was found on a resident, and the process of documenting patches on new admissions. Additionally, RN #2, RN #4, RN#10 and RN #11 were educated on the notification of the Director of Nursing and/or the Assistant Director of Nursing of new orders for [MEDICATION NAME]es, the admission process for [MEDICATION NAME]es documentation, placement checking of the patch and to conduct a complete body audit if the patch was not where it was supposed to be and conduct an investigation, and the disposal process for the patches which includes two (2) licensed nursing staff to witness and destroy the patch by folding it and placing it in a Sharp's container. Interviews with CNA #1, CNA #2, CNA #3, and CNA #4, on 04/09/14 between 10:15 AM and 10:45 AM, revealed they were inserviced on reporting to the Charge Nurse if while performing care to a resident, two (2) patches were found to be present on the resident. They stated they would fill out a "Stop and Watch" form and turn it in to the Charge Nurse. Review of the [MEDICATION NAME] Patch Audits, on 04/08/14 and 04/09/14 revealed all new [MEDICATION NAME] orders were reported to the DON and/or ADON. The DON and ADON completed audits of residents who were currently on a [MEDICATION NAME] of any kind with the last audit completed on 04/08/14 and to continue every day for seven (7) days. The facility did not have any new admissions on [MEDICATION NAME]es at this time. On 04/03/14, the Medical Director was notified of the AoC and agreed with the plan with a verified signature. Review of the Quality Assurance meeting notes, dated 01/01/14, revealed the AoC was discussed via a phone call between the Medical Director and the Executive Director. Review of the PI Committee meeting documentation, dated 01/01/14 through 03/19/14 revealed meetings were held weekly to review all audits, new admissions with [MEDICATION NAME]es, and revise the care plans to ensure resident's individual needs were met and residents were receiving care to meet the highest practicable well being. Interviews conducted with the ADON, DON, and the Executive Director, on 04/09/14, revealed medication administration was discussed in the PI meetings as stated in the AoC and training was provided to licensed nursing staff as well as the CNAs related to identifying multiple patches on residents or a patch on a resident on initial admission to the facility.

Based on interview, record review, and review of the Hospital History and Physical, facility's Investigation Report, Medication Administration Policy, and the Nursing Drug Handbook it was determined the facility failed to have an effective system to ensure medication was administered according to the professional standards addressing the (5) five rights of medication administration for one (1) of twelve (12) sampled residents (Resident #3). On 11/27/13 at approximately 7:30 AM, Licensed Practical Nurse (LPN) #3, who was in orientation with LPN #4, administered Resident #3's roommate's medication to Resident #3 without ensuring he/she was the right resident and without LPN #4 being present. Resident #3 was administered eight (8) medications that were not prescribed for him/her which included antihypertensives. The LPN failed to compare the resident to the resident's picture, and failed to ask the resident his/her name. In addition, the LPN failed to have the medication cart in the adjacent area to the resident's room to enable her to access the resident's picture. Resident #3's blood pressure dropped from 110/62 mmHg (normal for resident) at 7:30 AM to 72/42 mmHg at 9:30 AM. At approximately 10:00 AM, the physician ordered Normal Saline 500 milliliters (ml) Intravenous (IV) bolus and to send the resident to the emergency room for evaluation. On arrival at the hospital, the resident complained of dizziness, the resident's blood pressure was low and his/her heart rate dropped into the 30's at approximately 10:53 AM. Resident #3 was admitted to the hospital with [REDACTED]. Resident #3 was discharged back to the nursing facility on 12/01/13. (Refer to F333) In addition, interview and review of the facility's Nursing Competency revealed LPN #3's competency in medication administration had not been validated per the facility's policy. The facility's failure to ensure medication was administered according to the nursing standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/31/14, and was determined to exist on 11/27/13. The facility was notified of the Immediate Jeopardy on 01/31/14. An acceptable Allegation of Compliance (AoC) was received on 02/06/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 02/11/14, as alleged. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC) and facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Nursing 2007 Drug Handbook. (2007) Lippincott Williams & Wilkins: Philadelphia, Pennsylvania revealed the overwhelming task of ensuring medication safety can be managed by consistently using the five rights of drug administration: The right drug, right route, right dose, right time and right patient. Further review revealed the right patient should be confirmed by checking the patient's identification, and asking the resident's their name. Review of the facility's Nursing Competency revealed an assessment of clinical competency of nursing personnel would be completed during the orientation period. Validation for clinical competency would be completed during orientation with the Director of Nursing/Director of Staff Development. Review of the facility's Medication Administration Policy/Procedure, last revised 03/2010, revealed residents should be identified prior to administration of medications. Residents should be identified using two (2) identifiers prior to medication administration. Room numbers should not be used as one (1) of two (2) identifiers. The procedure was to use one (1) of the following procedures: 1.) Compare the name on the arm band with the name on the MAR/TAR(Medication Administration Record/Treatment Administration Record) and compare to the photo of the resident to the resident. 2.) Ask the resident his or her full name and compare it to the name on the MAR/TAR and compare the resident's photo to the resident. 3.) If there is no photo or armband, and the resident is unable to tell you his or her name, then validate the resident's identity with a second associate who is familiar with the resident and compare the resident's written name to the MAR/TAR. Review of the facility's investigation, dated 11/28/13, revealed Resident #3 received incorrect medication on 11/27/13. LPN #3 entered the resident's room and called Resident #3's roommate's name and Resident #3 answered and sat up in the bed. LPN #3 administered Resident #3's roommate's medications to Resident #3. Resident #3's blood pressure was assessed and was 110/62 mmHg which was within normal limits for him/her according to the investigation. Further review revealed the resident began to decline becoming hypotensive (low blood pressure) which resulted in the resident being sent to the hospital where he/she was admitted for overdose and low blood pressure. Further review revealed there was no evidence the LPN compared Resident #3's roommate's picture to Resident #3 or asked Resident #3 his/her name. Review of the Hospital History and Physical, dated 11/28/13 at 7:49 AM, revealed Resident #3 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged back to the facility on [DATE]. Review of Resident #3's November 2013 Medication Administration Record (MAR), revealed on 11/27/13 the medications scheduled for 7:00 AM were circled indicating the resident did not receive his/her ordered medications. Review of Resident #3's roommate's November 2013 MAR revealed the medications given in error to Resident #3 were [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 100 milligram (mg), [MEDICATION NAME] (anti-depressant) 90 mg, [MEDICATION NAME] (anti-hypertensive) 160 mg, K-Dur (potassium supplement) 20 mg, [MEDICATION NAME] (antihypertensive) 40 mg, [MEDICATION NAME] (antihypertensive) 100 mg, a multivitamin, and UTI Stat (urinary tract infection preventative) 30 milliliters (ml). Interview with LPN #3, on 01/28/14 at 12:44 PM and on 01/31/14 at 8:46 AM, revealed she entered Resident #3's room with the roommate's medication and when she called the resident's roommate's name, Resident #3 answered. She stated she gave Resident #3 the roommate's medication because Resident #3 answered when she called his/her roommate's name. LPN #3 stated when she passed the medication to Resident #3 she did not have the medication cart outside of the room; therefore, she did not have ready access to the MAR and the resident's photo. However, she stated Resident #3's photo did not look like him/her. LPN #3 stated she was aware of the facility's policy related to identifying the resident by using the photograph and asking the resident his/her name. She stated she should have asked another staff to go with her to identify the resident. Further interview revealed she did not take the medication cart with her to the room because during orientation she had observed other nurses leave the cart at the nurse's station if the resident's room was close. In addition, LPN #3 stated she was allowed to pass medication on her own on 11/21/13 from 1:20 PM to 7:00 PM because LPN #4 had to leave. Interview with LPN #4, on 01/28/14 at 11:35 AM and on 01/30/13 at 3:22 PM, revealed she was training LPN #3 on 11/27/13 when the incident occurred. She stated she had observed LPN #3 prepare medications for administration and watched her administer the medications a couple of times prior to the incident. She stated she had no concerns with LPN #3's ability to perform the task and had signed off a hand written competency check list on 10/19/13 revealing she and LPN #3 felt confident in LPN #3 passing medication. LPN #4 stated she was with LPN #3 on 11/27/13 during the medication pass. She stated she had gone inside the Nurses' Station while LPN #3 was preparing Resident #3's roommate's medications at the medication cart which was at the Nurses' Station. LPN #4 stated when she got up to go around the Nurse's Station to go to the room with LPN #3, LPN #3 had already taken the medications to the room and administered them to the wrong resident. She stated she was never more than two (2) to three (3) feet away while LPN #3 was passing medications and was available for any assistance needed. Further interview with LPN #4 revealed on 11/21/13 she had to leave early around 1:20 PM, and LPN #3 had to pass medications and work alone until 7:00 PM without licensed staff with her. Interviews with Registered Nurse (RN) #1, RN #2, LPN #1, LPN #2, and LPN #5, on 01/28/14 at 3:15 PM, on 01/29/14 at 10:33 AM and 10:42 AM, on 01/30/14 at 3:45 PM, and on 02/01/14 at 8:30 AM respectively, revealed they had been trained to identify a resident by "asking" the resident his or her full name and by looking at the photo in the MAR. The licensed staff revealed they were also trained to ask another associate if in doubt of a resident's ability to provide accurate identification. Interview with the Staff Development Coordinator (SDC), on 01/29/14 at 2:39 PM and on 01/30/14 at 3:10 PM, revealed the nursing staff received a two (2) day classroom orientation which included medication administration. She revealed the licensed staff was then assigned to a nurse on the unit to learn the actual procedures for medication administration. She stated she depended on feedback from the unit nurses to acquire the information needed to decide if a new employee required increased orientation time. She stated the typical orientation period was for ten (10) days, but more time was given if needed. The decision when a new nurse was ready to be on his/her own was a collaborative effort between the Unit Managers, Charge Nurses, SDC, and the Director of Nursing (DON). Additionally, she stated the competency check list was reviewed at the end of the ten (10) days by her and the new employee with any concerns addressed at that time. She stated LPN #3 was hired on an "as needed" basis and had not completed her ten (10) days at the time of the incident. In addition, she had not reviewed the competency check list and was not involved in the decision for LPN #3 to work independently. Interview with the DON, on 01/29/14 at 5:31 PM and on 01/30/13 at 3:52 PM, revealed LPN #3 had worked since the incident on 11/27/13 but had not passed medications again. She stated LPN #3 should have been competent enough to double check the identity of Resident #3. Additionally, she stated she felt LPN #3 was ready to pass medications on her own, even though LPN #3 had not completed her ten (10) day orientation period, and stated there was always another associate there if LPN #3 needed them. The DON stated the nursing staff should take the medication cart to the resident's room to have what was needed to administer medications safely and effectively. She stated it was not acceptable practice to leave the medication cart at the nurse's station and walk the medications to the residents' rooms. Interview with the Executive Director (ED), on 01/29/14 at 5:15 PM, revealed LPN #3 received in-servicing prior to being allowed to pass any medications. The ED stated she did not feel there was a system problem, but the cause of the incident was human error. Interview with Resident #3, whom the facility assessed as interviewable, on 01/29/14 at 11:35 AM, revealed he/she thought he/she was going to die after getting the wrong medications. He/ She stated some of the medications were big pills and hard to swallow, therefore the pills were given in applesauce so the medication was unidentifiable. Additionally, the resident stated he/she now request the medications be brought into the room unopened so the medications can be identified by him/her prior to taking them. **The facility implemented the following actions to remove the Immediate Jeopardy: On 11/27/13, the Director of Nursing (DON) interviewed LPN #3 related to the cause of the medication error and determined LPN #3 required increased training in medication administration prior to administering more medications. LPN #3 received one on one training from the Staff Development Coordinator (SDC) related to Medication Administration, including the five (5) rights of medication administration (right resident, right medication, right time, right dosage and right route) which included a competency exam at the end of the training. LPN #3 had adminstered four other residents (Resident #1, #9, #10 and #11's) medication on 11/27/13. The Administrator reviewed each resident's individual MAR for missed medications an/or discrepancies. The records were reviewed for any changes in condition. All four resident were seen by the physician. On 01/09/14, education on medication administration, to include the five rights of medication administration was conducted by the DON and the SDC during a nurse meeting. To determine the licensed nursing staff had understood the inservice, each nurse had to demonstrate understanding to the DON and take a competency exam. Any nurses who did not attend the 01/09/14 inservice for any reason would have the same training and take the competency exam by 02/02/14. After a new hired nurse completed class room orientation, the SDC, DON, or Assistant DON (ADON) would provide oversight as the new nurse employee performs his/her first medication administration pass to validate the nurse is following correct procedures for medication administration to include the five rights of medication administration correctly and would document this in the nurses file and report to the DON and Executive Director (ED) that the nurse was safe to perform medication administration. Any nurse not following the medication administration procedures would be removed from the patient care area and re-trained by the DON, ADON, or SDC and have oversight provided for the next medication pass. Monitoring and System Change: The DON, ADON, or SDC will complete a medication administration audit of 100% of licensed nurse staff to ensure compliance with medication administration to include the five rights of medication administration. Each nurse (LPN or RN) will be observed for a minimum of five (5) residents during medication administration during their shift. If any nurse does not follow the proper procedures for medication administration, they will be immediately removed from patient care area and re-educated by DON, ADON, or SDC and monitored again during medication administration. The medication administration audit began January 31, 2014 at 9 PM and will continue with each nurse's medication administration pass until every nurse has been audited during a medication administration pass. On 02/03/14 the DON, ADON, or SDC began a seven (7) day a week medication administration audit of two (2) nurses for thirty (30) days, then three (3) days a week medication administration audits of two (2) nurses for the next thirty (30) days, then one (1) day a week medication audits of two (2) nurses for the next thirty (30) days. The results of the audits will be reviewed by the PI Committee and if any nurse does not follow the proper procedures for medication administration, the nurse will be removed from the patient care area and re-educated by the DON, ADON, or SDC and have monitoring again of a medication administration pass. Medication audits will validate the care plans are being followed per physician orders. The Medication cart will be taken with each nurse on their routine medication pass. A small pocket/hand size picture album containing a picture of each resident, labeled and in alphabetical order, has been made for each medication cart so the nurse can carry the resident picture album with them for as needed (PRN) medications or other situations in which resident identification is needed, without the need for the medication cart. An inservice related to the use of the photo album was completed on 02/05/14 and included the reason for the album as well as the need to take the medication cart to the resident's room with the Medication Administration Record (MAR) if the photo album was not going to be used. If any nurse missed the inservice, the DON, ADON, or SDC was to meet with each nurse individually to assure training on the new photo album prior to their shift. The DON, ADON, or SDC will monitor two (2) nurses daily for thirty (30) days, two (2) nurses three (3) days a week for the next thirty (30) days and two (2) nurses one (1) day a week for 30 days, to ensure nurses have the MAR binder or the picture album with them for PRN medications or other situations where resident identification is needed. Any nurse not having the MAR binder or the photo album during medication administration will be removed from the patient care area and re-educated by the DON, ADON, or SDC to ensure the importance of having the resident identification available during medication administration. Education related to the photo album will be added to new employee orientation for nursing staff and the monitoring outcomes will be taken to the Performance Improvement (PI) Committee for review. All residents pictures were updated by the Executive Director (ED) and Medical Records Clerk on 02/05/14 and placed in the MARS and Treatment Administration Records (TARS) and photo albums were completed by the ED, DON, ADON, and Activities Director. The pictures are to be reviewed quarterly by medical records staff and/or upon any change in condition that may affect a resident's personal appearance, to ensure the photo in the MAR or photo album reflects the most current appearance of the resident. The Administrator is responsible to monitor the process to ensure quarterly and as needed meetings, and report to the PI Committee of the outcomes. Performance Improvement Committee: The Center will add the option of MAR binder or hand/pocket size photo album as an option for resident identification to the medication administration policy. The hand size photo album was made available to nursing staff to assist in resident identification when administering a PRN medication or for any other situation where the medication cart may not be needed at the resident's room. The photo album will be added to the orientation policy given to any new nurse employee. The ED notified the Medical Director of the Immediate Jeopardy on 01/31/14 at 8:15 PM. The Allegation of Compliance (AoC) was reviewed with the Medical Director for approval and any new suggestions on 02/01/14 and on 02/05/14. The PI Committee met on 02/01/14 and on 02/05/14 to review the AoC and to validate completion of staff education, photo album in place, resident's photos updated and monitoring of photos in place. The PI Committee consists of the Administrator, DON, ADON, SDC, Minimum Data Set (MDS) nurse, Social Services Director, Activities, Medical Director, Medical Records and other staff as needed. The PI Committee will meet weekly for thirty (30) days to review the medication audits monitoring, resident identification monitoring, medication errors if any and root causes, that all new nursing staff have had all medication administration education including an audit of the first medication administration pass and ensure the employee file reflects the training and validation. The PI Committee will meet two (2) times a month for the next thirty (30) days and then monthly thereafter to monitor the above mentioned and make changes and/or suggestions as needed to stay in compliance. **The State Survey Agency validated the corrective action taken by the facility as follows: Review of an Education Acknowledgment Form, dated 11/27/13, revealed LPN #3 received one on one training from the SDC related to medication administration guidelines including the five (5) rights of medication administration and how to identify the resident appropriately. Review of memos posted, on 11/28/13, at each nursing station revealed staff was to read and sign the memo related to the five (5) rights of medication administration as well as the policy related to resident identification. Review of an in-service provided to the licensed nursing staff, on 01/09/14 at 7:00 AM and 1:30 PM, revealed all licensed staff employed at the facility received training related to pharmacy and medication pass, medicare, behavior, and nursing documentation, incident reports, and fall/skin injury assessment. Staff also demonstrated a medication administration pass and completed a check off list and also completed a pharmacy review quiz. Interview with the ED, on 02/03/14 at 1:15 PM, revealed every nurse in the facility had been trained over the weekend and each nurse had been checked off on a medication administration pass which included medication administered to five (5) residents. Additionally, every nurse was trained on proper resident identification. Interviews with RN #1 and RN #2, on 02/11/14 at 9:25 AM and on 02/10/14 at 1:45 PM respectively, revealed an inservice was conducted on 02/07/14 with nursing staff related to the use of the new photo album to be used in resident identification during a PRN medication pass, blood sugar finger sticks, or for any other reason the medication cart may not be needed at the resident room. Additionally, the in-service was related to identifying the resident by asking his/her full name when entering the room and if the resident was unable to give an appropriate name then another staff member was to be consulted to aide in the proper identification of the resident. Interviews with LPNs #1 and #6, on 02/10/14 at 3:05 PM and 1:50 PM respectively, revealed there was an in-service conducted on Friday, 02/07/14 related to medication administration and proper identification of the resident as well as the five (5) rights to medication administration. Additionally, the purpose of the new photo albums was discussed as well as checking the medication three (3) times prior to administration to assure the five (5) rights were being followed. Interviews with LPNs #2, #7, #9, #5, and #8, on 02/11/14 at 9:00 AM, 12:25 PM, 12:30 PM, 12:40 PM, and 12:42 PM, revealed an in-service was conducted on Friday, 02/07/14 related to medication administration and proper identification of the resident as well as the five (5) rights to medication administration. Additionally, the purpose of the new photo albums was discussed as well as checking the medication three (3) times prior to administration to assure the five (5) rights were being followed and it was re-enforced that if the resident was unable to identify themselves, then another associate should be consulted to aide in the resident's identity. Review of Residents #1, #9, #10 and #11's care plans revealed an intervention to provide medications as ordered. In addition, record reviews revealed the residents were seen by their physicians with no change in conditions identified and there were no identified changes in the residents noted. Observation of medication administration passes, on 02/10/14 at 1:50 PM and 3:05 PM, revealed LPN #6 and LPN #1 passing medications following the facility's policy and procedure except for asking the resident his/her full names when entering the room. However, they did call the residents by his/her first names prior to administering medications to them. When asked why they didn't ask the residents their full names, they both explained that they have known these residents for a long time, but if the residents were new to the facility and if there was a question of the resident's identity, then another associate would be asked to assist in identifying the resident. The photo albums were on the medication cart and were being used accordingly. Interview with the ED and the DON, on 02/11/14 at 2:12 PM, revealed the QA committee is meeting weekly for thirty (30) days to review the medication audit monitoring, the resident identification monitoring, medication errors if any and root causes, that all new nursing staff have had all medication administration education, been audited on first medication administration pass and employee reflects this training and validation. The PI committee will meet two (2) times a month for next thirty (30) days and then monthly thereafter to monitor the above mentioned and make changes or suggestions as needed to stay in compliance.

Based on observation, interview, record review, and review of the Pre-Hospital Care Report, Hospital History and Physical, Hospital Discharge Summary, Facility's Investigation Report, and the facility's Medication Administration and Administration of Medication policy/procedures, it was determined the facility failed to ensure one (1) of fifteen (15) sampled residents (Resident #3) was free of any significant medication errors. The facility failed to ensure staff followed the facility's policy and procedure related to ensuring medication was administered to the right resident. The licensed staff failed to check the resident's picture, ask the resident's name and/or have other staff identify the resident. Resident #3 received another resident's medication which resulted in a significant medication error. The facility administered the following medications to Resident #3 in error: [MEDICATION NAME] (anti-[MEDICAL CONDITION]) 100 milligram (mg), [MEDICATION NAME] (antidepressant) one (1) 30 mg and one (1) 60 mg capsule, [MEDICATION NAME] (antihypertensive) 160 mg, K-Dur (potassium supplement) 20 mg, [MEDICATION NAME] (antihypertensive) 40 mg, [MEDICATION NAME] (antihypertensive) 100 mg, a multivitamin, and 30 milliliter UTI Stat (prevention of urinary tract infection). Resident #3 was sent to the hospital and diagnosed with [REDACTED]. Resident #3 was hospitalized for [REDACTED]. On 11/27/13, Licensed Practical Nurse (LPN) #3 administered Resident #3 his/her roommate's medications during the morning medication pass at approximately 7:30 AM. Resident #3 was administered eight (8) medications that were not prescribed for him/her which included antihypertensives which resulted in a significant medication error. LPN #3 identified the significant medication error and reported it to LPN #4 immediately at which time the resident was assessed. The resident's blood pressures ranged from 110/62 mmHg (normal for resident) at 7:30 AM to 72/42 mmHg at 9:30 AM. The physician was notified with orders received to hold the resident's medications until 4:00 PM and to monitor his/her blood pressure every hour. At approximately 10:00 AM, the physician gave orders to start an Intravenous (IV) bolus of 500 cc Normal Saline and send the resident to the emergency room for evaluation. The resident continued to decline and became hypotensive. The resident's heart rate dropped into the thirtys (30s). The resident was sent to the hospital where he/she was admitted for beta blocker overdose and low blood pressure. Resident #3 was admitted for four (4) days and returned to the facility on [DATE]. Refer to F281 and F282. The facility's failure to ensure that residents were free from significant medication errors has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/31/14, and was determined to exist on 11/27/13. The facility was notified of the Immediate Jeopardy on 01/31/14. An acceptable Allegation of Compliance (AoC) was received on 02/06/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 02/11/14, as alleged. A partial extended survey was conducted on 02/11/14. The scope and severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC) and facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure titled "Medication Administration (Identification of Residents When Administering Medications)" Standards of Practice, revised 03/10 revealed "Residents are identified prior to administration of medications. Residents are identified using two (2) identifiers prior to medication administration. Room numbers are not used as one (1) of the two (2) identifiers. The procedure included comparing the name with the name on the Medication Administration Record (MAR) and compare the photo of the resident to the resident. Ask the resident his/her full name and compare it to the name on the MAR and compare the resident's photo to the resident. If there is no photo, and the resident was unable to tell his/her full name, then the nurse was to validate the resident's identity with a second associate who was familiar with the resident and compare the name to the MAR. Review of the facility's policy and procedure titled "Administration of Medication" revised 10/04, revealed Standard, "All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnoses. Policy revealed it was the responsibility of the nursing professional to be aware of the classification, action, correct dosage, and side effects of a medication before administration. A physician order [REDACTED]. Procedure revealed nursing staff was to bring the medication cart to an area adjacent to the resident's room. Record review revealed the facility admitted Resident #3 on 10/29/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment, dated 01/02/14, revealed the facility assessed Resident #3's cognition as moderately impaired with a Brief Interview Mental Status (BIMS) score of twelve (12). Review of the Comprehensive Care Plan, last revised 01/02/14, revealed an intervention for Resident #3 to receive medications as ordered. Review of Resident #3's November 2013 MAR revealed on 11/27/13 the medications ordered by the physician to be administered at 7:00 AM were circled indicating the resident did not receive the medications. The medications Resident #3 was scheduled to receive, on 11/27/13 at 8:00 AM, included a [MEDICATION NAME] Patch 100 mcg (microgram) (pain patch), [MEDICATION NAME] (diuretic) 20 mg, [MEDICATION NAME] (antihypertensive) 25 mg, [MEDICATION NAME] (antihypertensive) 25 mg, [MEDICATION NAME] Nasal Spray ([MEDICATION NAME]), [MEDICATION NAME] (antibiotic), [MEDICATION NAME] (antibiotic), [MEDICATION NAME] (antiinfective), Otic drops, [MEDICATION NAME] (antidepressant) 15 mg, Tums (antiacid) and [MEDICATION NAME] (antianxiety) one (1) mg, as needed for anxiety. Review of Resident #3's roommate's November 2013 MAR, revealed the medications given to Resident #3 in error were [MEDICATION NAME] ([MEDICAL CONDITION])100 milligram (mg), [MEDICATION NAME] (antidepressant) 90 mg, [MEDICATION NAME] (antihypertensive)160 mg, K Dur (potassium supplement) 20 mg, [MEDICATION NAME] (antihypertensive) 40 mg, [MEDICATION NAME] (antihypertensive) 100 mg, a multivitamin, and UTI Stat 30 ml. (urinary tract infection preventative). Review of the Nurse's Notes, dated 11/27/13 at 9:42 AM, revealed Resident #3 was administered his/her roommate's medications by LPN #3 at approximately 7:30 AM. LPN #3 identified the mistake and reported it to LPN #4 immediately at which time the resident was assessed and his/her blood pressure was taken every fifteen (15) minutes. The resident's blood pressures ranged from 110/62 mmHg (millimeters of mercury) (normal for resident) at 7:30 AM to 72/42 mmHg at 9:30 AM. The physician was notified and instructions were received to hold the resident's medications until 4:00 PM on 11/27/13; and, to monitor the blood pressure every hour. At approximately 10:00 AM, the physician gave orders to start an Intravenous (IV) bolus of 500cc of Normal Saline and to send the resident to the emergency room for evaluation. Review of the Pre-hospital Care Report, dated 11/27/13 at 10:38 AM, revealed at 10:39 AM the ambulance arrived and made contact with the resident at 10:41 AM. The resident was lying in bed in a supine position with his/her feet up and an IV was in the left wrist that was not patent. The resident complained of dizziness. The resident's blood pressure was low (125/55 mmHg) and heart rate was 52. The resident blood pressure and heart rate continued to drop and at 10:53 AM when the resident left the facility his/her heart rate dropped into the 30's. An IV access was successful at 11:09 AM and at 11:11 AM [MEDICATION NAME] (antiarrythmic) 0.5mg was given IV piggyback with an improvement noted in the heart rate. Review of the Hospital History and Physical, dated 11/28/13 at 7:49 AM, and the Hospital Discharge Summary, dated 12/01/13 at 8:59 AM, revealed Resident #3 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted to the hospital for four (4 ) days and was discharged back to the facility on [DATE]. The summation of the History and Physical revealed the resident presented to the emergency room after accidentally receiving an excessive amount of beta-blockers that produced marked [MEDICAL CONDITION] which required treatment by the cardiology group. Review of the facility's investigation, dated 11/28/13, revealed Resident #3 received incorrect medication. LPN #3 entered the resident's room and called Resident #3's roommate's name and Resident #3 answered and sat up in the bed. Resident #3's roommate's medications were given to him/her by mistake. Resident #3's blood pressure was assessed and was 110/62 mmHg which was within normal limits for him/her according to the investigation. The resident began to decline becoming hypotensive (low blood pressure) resulting in the resident being sent to the hospital where he/she was admitted for beta blocker overdose and low blood pressure. Interview with LPN #3, on 01/28/14 at 12:44 PM and on 01/31/14 at 8:46 AM, revealed she entered Resident #3's room and called the resident's roommate's name; Resident #3 answered and she gave him/ her the medication. LPN #3 stated she should have gone back and checked the photo in the MAR and had someone else to go with her to identify the resident. She further stated when she passed the medication to Resident #3 she did not have the medication cart outside of the room, therefore, she did not have ready access to the MAR where the resident's photo was and if the MAR had been in front of her, the mistake may not have occurred. Interview with LPN #4, on 01/28/14 at 11:35 AM and on 01/30/14 at 3:22 PM, revealed she was training LPN #3 on 11/27/13 when the incident occurred. She stated she had observed LPN #3 preparing and administering medications a couple of times prior to the incident. She stated she had no concerns with LPN #3's ability to perform the task and had signed off a hand written competency check list revealing she felt confident with medication pass. LPN #4 stated she was with LPN #3 during the medication pass and she had gone into the nurse's station to look at bowel movement (BM) logs. She stated she could see LPN #3 was preparing Resident #3's roommate's medications at the medication cart sitting at the nursing station. She stated when she got up to go around the nurse's station to go to the room with LPN #3, LPN #3 had already taken the medications to the room and had administered them to the wrong resident. She revealed she was never more than two (2) to three (3) feet away while she was passing medications and was available for any assistance needed. Interviews with Registered Nurse (RN) #1, RN #2, LPN #1, LPN #2, and LPN #5 on 01/28/14 at 3:15 PM, on 01/29/14 at 10:33 AM and 10:42 AM, on 01/30/14 at 3:45 PM, and on 02/01/14 at 8:30 AM respectively, revealed they had been trained to identify a resident by asking the resident his or her full name and by looking at the photo in the MAR. The licensed staff stated the identifiers on the doors were not used as they get moved around and switched at times. They also stated they were trained to ask another associate if in doubt of a resident's ability to provide accurate identification. Interview with the Director of Nursing (DON), on 01/29/14 at 5:31 PM, revealed LPN #3 had worked since the incident on 11/27/13 but had not passed medications again. She revealed she did not believe the incident should have occurred and LPN #3 should have been competent enough to double check the identity of Resident #3. Additionally, she stated she felt LPN #3 was ready to pass medications on her own and there was always another associate there if she needed them. Further interview on 01/30/14 at 3:52 PM, revealed nursing staff should take the medication cart to the resident's room to have what was needed to administer medications safely and effectively. She stated it was not acceptable practice to leave the medication cart at the nurse's station and walk the pills to the resident's rooms. Interview with the Executive Director (ED), on 01/29/14 at 5:15 PM, revealed LPN #3 received in-servicing prior to being allowed to pass any medications and she did not feel like a systems process was the cause of the incident but rather human error. Additionally, she revealed she did not feel Resident #3 receiving the wrong medication caused any [MEDICATION NAME] harm but could have caused increased anxiety levels. She stated the resident was alert and coherent when she left the faciity on [DATE] after the incident and she was not in fear for the resident's life. Interview with Physician #1, on 01/29/14 at 2:55 PM, revealed the medication Resident #3 received could have been life threatening. She stated she did see the resident in the hospital and did not feel the resident had any significant [MEDICATION NAME] side effects from receiving the wrong medications. Interview with Resident #3, on 01/29/14 at 11:35 AM, revealed the resident thought he/she was going to die after getting the wrong medications. The resident stated some of the medications are big pills and are hard to swallow; therefore, the pills are given in applesauce so the appearance of the medication is unidentifiable. The resident revealed he/she had requested that his/her medications be brought into the room unopened so they may be identified by him/her prior to taking them. **The facility implemented the following actions to remove the Immediate Jeopardy: On 11/27/13, the Director of Nursing (DON) interviewed LPN #3 related to the cause of the medication error and determined LPN #3 required increased training in medication administration prior to administering more medications. LPN #3 received one on one training from the Staff Development Coordinator (SDC) related to Medication Administration, including the five (5) rights of medication administration (right resident, right medication, right time, right dosage and right route) which included a competency exam at the end of the training. LPN #3 had adminstered four other residents (Resident #1, #9, #10 and #11's) medication on 11/27/13. The Administrator reviewed each resident's individual MAR for missed medications an/or discrepancies. The records were reviewed for any changes in condition. All four resident were seen by the physician. On 01/09/14, education on medication administration, to include the five rights of medication administration was conducted by the DON and the SDC during a nurse meeting. To determine the licensed nursing staff had understood the inservice, each nurse had to demonstrate understanding to the DON and take a competency exam. Any nurses who did not attend the 01/09/14 inservice for any reason would have the same training and take the competency exam by 02/02/14. After a new hired nurse completed class room orientation, the SDC, DON, or Assistant DON (ADON) would provide oversight as the new nurse employee performs his/her first medication administration pass to validate the nurse is following correct procedures for medication administration to include the five rights of medication administration correctly and would document this in the nurses file and report to the DON and Executive Director (ED) that the nurse was safe to perform medication administration. Any nurse not following the medication administration procedures would be removed from the patient care area and re-trained by the DON, ADON, or SDC and have oversight provided for the next medication pass. Monitoring and System Change: The DON, ADON, or SDC will complete a medication administration audit of 100% of licensed nurse staff to ensure compliance with medication administration to include the five rights of medication administration. Each nurse (LPN or RN) will be observed for a minimum of five (5) residents during medication administration during their shift. If any nurse does not follow the proper procedures for medication administration, they will be immediately removed from patient care area and re-educated by DON, ADON, or SDC and monitored again during medication administration. The medication administration audit began January 31,2014 at 9 PM and will continue with each nurse's medication administration pass until every nurse has been audited during a medication administration pass. On 02/03/14 the DON, ADON, or SDC began a seven (7) day a week medication administration audit of two (2) nurses for thirty (30) days, then three (3) days a week medication administration audits of two (2) nurses for the next thirty (30) days, then one (1) day a week medication audits of two (2) nurses for the next thirty (30) days. The results of the audits will be reviewed by the PI Committee and if any nurse does not follow the proper procedures for medication administration, the nurse will be removed from the patient care area and re-educated by the DON, ADON, or SDC and have monitoring again of a medication administration pass. Medication audits will validate the care plans are being followed per physician orders. The Medication cart will be taken with each nurse on their routine medication pass. A small pocket/hand size picture album containing a picture of each resident, labeled and in alphabetical order, has been made for each medication cart so the nurse can carry the resident picture album with them for as needed (PRN) medications or other situations in which resident identification is needed, without the need for the medication cart. An inservice related to the use of the photo album was completed on 02/05/14 and including the reason for the album as well as the need to take the medication cart to the resident room with the medication administration record (MAR) if the photo album was not going to be used. If any nurse missed the inservice, the DON, ADON, or SDC was to meet with each nurse individually to assure training on the new photo album prior to their shift. The DON, ADON, or SDC will monitor two (2) nurses daily for thirty (30) days, two (2) nurses three (3) days a week for the next thirty (30) days and two (2) nurses one (1) day a week for 30 days, to ensure nurses have the MAR binder or the picture album with them for PRN medications or other situations where resident identification is needed. Any nurse not having the MAR binder or the photo album during medication administration will be removed from the patient care area and re-educated by the DON, ADON, or SDC to ensure the importance of having the resident identification available during medication administration. Education related to the photo album will be added to new employee orientation for nursing staff and the monitoring outcomes will be taken to the Performance Improvement (PI) Committee for review. All residents pictures were updated by the Executive Director (ED) and Medical Records Clerk on 02/05/14 and placed in the MARS and Treatment Administration Records (TARS) and photo albums were completed by the ED, DON, ADON, and Activities Director. The pictures are to be reviewed quarterly by medical records staff and/or upon any change in condition that may affect a resident's personal appearance, to ensure the photo in the MAR or photo album reflects the most current appearance of the resident. The Administrator is responsible to monitor the process happens quarterly and as needed and report to the PI Committee of the outcomes. Performance Improvement Committee: The center will add the option of MAR binder or hand/pocket size photo album as an option for resident identification to the medication administration policy. The hand size photo album was made available to nursing staff to assist in resident identification when administering a PRN medication or for any other situation where the medication cart may not be needed at the resident's room. The photo album will be added to the orientation policy given to any new nurse employee. The ED notified the Medical Director of the Immediate Jeopardy on 01/31/14 at 8:15 PM. The Allegation of Compliance (AoC) was reviewed with the Medical Director for approval and any new suggestions on 02/01/14 and on 02/05/14. The PI Committee met on 02/01/14 and on 02/05/14 to review the AoC and to validate completion of staff education, photo album in place, resident's photos updated and monitoring of photos in place. The PI Committee consists of the Administrator, DON, ADON, SDC, Minimum Data Set (MDS) nurse, Social Services Director, Activities, Medical Director, Medical Records and other staff as needed. The PI Committee will meet weekly for thirty (30) days to review the medication audits monitoring, resident identification monitoring, medication errors if any and root causes, that all new nursing staff have had all medication administration education including an audit of the first medication administration pass and ensure the employee file reflects the training and validation. The PI Committee will meet two (2) times a month for the next thirty (30) days and then monthly thereafter to monitor the above mentioned and make changes and/or suggestions as needed to stay in compliance. **The State Survey Agency validated the corrective action taken by the facility as follows: Review of an Education Acknowledgment Form, dated 11/27/13, revealed LPN #3 received one on one training from the SDC related to medication administration guidelines including the five (5) rights of medication administration and how to identify the resident appropriately. Review of memos posted, on 11/28/13, at each nursing station revealed staff was to read and sign the memo related to the five (5) rights of medication administration as well as the policy related to resident identification. Review of an in-service provided to the licensed nursing staff, on 01/09/14 at 7:00 AM and 1:30 PM, revealed all licensed staff employed at the facility received training related to pharmacy and medication pass, medicare, behavior, and nursing documentation, incident reports, and fall/skin injury assessment. Staff also demonstrated a medication administration pass and completed a check off list as well completed a pharmacy review quiz. Interview with the ED, on 02/03/14 at 1:15 PM, revealed every nurse in the facility had been trained over the weekend and each nurse had been checked off on a medication administration pass which included medication administered to five (5) residents. Additionally, every nurse was trained on proper resident identification. Interviews with RN #1 and RN #2, on 02/11/14 at 9:25 AM and on 02/10/14 at 1:45 PM respectively, revealed an inservice was conducted on 02/07/14 with nursing staff related to the use of the new photo album to be used in resident identification during a PRN medication pass, blood sugar finger sticks, or for any other reason the medication cart may not be needed at the resident room. Additionally, the in-service was related to identifying the resident by asking his/her full name when entering the room and if the resident was unable to give an appropriate name then another staff member was to be consulted to aide in the proper identification of the resident. Interviews with LPNs #1 and #6, on 02/10/14 at 3:05 PM and 1:50 PM respectively, revealed there was an in-service conducted on Friday, 02/07/14 related to medication administration and proper identification of the resident as well as the five (5) rights to medication administration. Additionally, the purpose of the new photo albums was discussed as well as checking the medication three (3) times prior to administration to assure the five (5) rights were being followed. Interviews with LPNs #2, #7, #9, #5, and #8, on 02/11/14 at 9:00 AM, 12:25 PM, 12:30 PM, 12:40 PM, and 12:42 PM, revealed an in-service was conducted on Friday, 02/07/14 related to medication administration and proper identification of the resident as well as the five (5) rights to medication administration. Additionally, the purpose of the new photo albums was discussed as well as checking the medication three (3) times prior to administration to assure the five (5) rights were being followed and it was re-enforced that if the resident was unable to identify themselves, then another associate should be consulted to aide in the resident's identity. Observation of medication administration passes, on 02/10/14 at 1:50 PM and 3:05 PM, revealed LPN #6 and LPN #1 passing medications following the facility's policy and procedure except for asking the resident his/her full names when entering the room. However, they did call the residents by his/her first names prior to administering medications to them. When asked why they didn't ask the residents their full names, they both explained that they have known these residents for a long time, but if the residents were new to the facility and if there was a question of the resident's identity, then another associate would be asked to assist in identifying the resident. The photo albums were on the medication cart and was being used accordingly. Review of Residents #1, #9, #10 and #11's care plans revealed an intervention to provide medications as ordered. In addition, record reviews revealed the residents were seen by their physicians with no change in conditions identified and there were no identified changes in the residents noted. Interview with the ED and the DON, on 02/11/14 at 2:12 PM, revealed the QA committee is meeting weekly for 30 days to review the medication audit monitoring, the resident identification monitoring, medication errors if any and root causes, that all new nursing staff have had all medication administration education, been audited on first medication administration pass and employee reflects this training and validation. The PI committee will meet 2 times a month for next 30 days and then monthly thereafter to monitor the above mentioned and make changes or suggestions as needed to stay in compliance.

Based on observation, interview, record review, review of the Facility Investigation, Hospital History and Physical and the facility's Resident Care Plan policy and procedure it was determined the facility failed to ensure services provided or arranged by the facility were provided by qualified persons in accordance with the resident's written plan of care for one (1) of twelve (12) sampled residents (Resident #3). During a morning medication pass, the facility failed to administer medications as ordered per the care plan to Resident #3. Resident #3 was administered his/her roommate's medication which resulted in a medication overdose for Resident #3 requiring him/her to be hospitalized for [REDACTED]. On 11/27/13, Licensed Practical Nurse (LPN) #3 failed to follow Resident #3's care plan to administer medication as ordered when she administered Resident #3 his/her roommate's medication. Resident #3's medications had to be withheld due to the error. The medications given in error included [MEDICATION NAME] (anti-[MEDICAL CONDITION])100 milligram (mg), [MEDICATION NAME] (antidepressant) 90 mg, [MEDICATION NAME] (antihypertensive)160 mg, K Dur (potassium supplement) 20 mg, [MEDICATION NAME] (antihypertensive) 40 mg, [MEDICATION NAME] (antihypertensive) 100 mg, a multivitamin, and UTI Stat 30 ml (urinary tract preventative). LPN #3 identified the mistake and reported it to LPN #4 immediately at which time the resident was assessed and his/her blood pressures ranged from 110/62 mmHg (millimeters of mercury) at 7:30 AM, to 72/42 mmHg at 9:30 AM. At approximately 10:00 AM, the physician gave orders to start an Intravenous (IV) bolus of 500cc Normal Saline and send to the emergency room for evaluation. Resident #3 continued to decline becoming hypotensive (low blood pressure). The resident was sent to the hospital, on 11/27/13, where he/she was admitted for overdose and low blood pressure. Resident #3 returned to the facility on [DATE]. The facility's failure to implement the care plan related to the administration of medications as ordered by the physician has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/31/14, and was determined to exist on 11/27/13. The facility was notified of the Immediate Jeopardy on 01/31/14. An acceptable Allegation of Compliance (AoC) was received on 02/06/14 and the State Survey Agency validated the Immediate Jeopardy was removed on 02/11/14, as alleged. A partial extended survey was conducted on 02/11/14. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC) and facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure, titled "Resident Care Plan", last revised 12/2008, revealed a Resident Care Plan was a brief written portrait of the resident and an individualized guide of the nursing care needed with components including medications and treatments. "An essential component of the care plan was methods, approaches, or plan: description of what is actually going to be done for, to, or with the resident in order to achieve goals" and to identify the discipline that was responsible for each element of care. Record review revealed the facility admitted Resident #3 on 10/29/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/02/14, revealed the facility assessed Resident #3's cognition as moderately impaired with a Brief Interview Mental Status (BIMS) score of twelve (12) indicating the resident was interviewable. Review of the Comprehensive Care Plan, last revised 01/02/13, revealed an intervention to administer medications as ordered. Review of Resident #3's November 2013 Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of the facility's investigation, dated 11/28/13, revealed Resident #3 received incorrect medication on the morning of 11/27/13. LPN #3 entered the resident's room and called Resident #3's roommate's name; Resident #3 answered and sat up in the bed. Resident #3's roommate's medications were given to Resident #3 in error. Resident #3's blood pressure was assessed and was 110/62 mmHg which was within normal limits for him/her according to the investigation. The resident began to decline becoming hypotensive (low blood pressure) resulting in the resident being sent to the hospital where he/she was admitted for beta blocker overdose and low blood pressure. Review of Resident #3's roommate's November 2013 MAR, revealed the medications given to Resident #3 in error were [MEDICATION NAME] ([MEDICAL CONDITION])100 milligram (mg), [MEDICATION NAME] (antidepressant) 90 mg, [MEDICATION NAME] (antihypertensive)160 mg, K Dur (potassium supplement) 20 mg, [MEDICATION NAME] (antihypertensive) 40 mg, [MEDICATION NAME] (antihypertensive) 100 mg, a multivitamin, and UTI Stat 30 ml. (urinary tract infection preventative). Review of the Nursing Notes, dated 11/27/13 at 9:42 AM, revealed Resident #3 was administered his/her roommate's medications by LPN #3 at approximately 7:30 AM. LPN #3 identified the error and reported it to LPN #4 immediately at which time the resident was assessed and his/her blood pressure was taken. The resident's blood pressures were 110/62 mmHg at 7:30 AM; 100/60 mmHg at 8:00 AM and 8:30 AM; 90/60 mmHg at 9:00 AM; and 72/42 mmHg at 9:30 AM. The Physician was notified and orders were received to hold the resident's medications until 4:00 PM on 11/27/13 and to monitor the resident's blood pressure every hour. At approximately 10:00 AM, the physician gave orders to start an Intravenous (IV) bolus of 500cc Normal Saline and send the resident to the emergency room for evaluation. Review of the Hospital History and Physical dated, 11/28/13 at 7:49 AM, revealed Resident #3 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged back to the facility on [DATE] after being hospitalized for [REDACTED]. Interview with LPN #3, on 01/28/14 at 12:44 PM, revealed she entered Resident #3's room and called the resident's roommate's name; Resident #3 answered and she gave him/ her the medication because he/she answered to his/her roommate's name. LPN #3 stated she should have gone back and checked the photo in the MAR, even though she did not think the photo in the MAR indicated [REDACTED]. Interview on 01/31/14 at 8:46 AM, revealed when LPN #3 passed the medication to Resident #3 she did not have the medication cart outside the room. She did not have ready access to the MAR indicated [REDACTED]. Interview with LPN #4, on 01/28/14 at 11:35 AM, revealed she was training LPN #3 on 11/27/13 when the incident occurred. She stated she had observed LPN #3 preparing the medications for pass and administering the medications a couple of times prior to the incident. LPN #3 was preparing Resident #3's roommate's medications at the medication cart sitting at the Nurses' Station. She stated she was looking at the BM logs and when she got up to go around the Nurses' Station to go to the room with LPN #3, she had already taken the medications to the room and administered them to the wrong resident. Interviews with LPNs # 1, on 01/29/14 at 10:42 AM, LPN #2, on 01/28/14 at 3:15 PM, and LPN #5, on 01/30/14 at 3:45 PM, as well Registered Nurses (RN) #1 on 01/29/14 at 10:33 AM, and RN #2, on 02/01/14 at 8:30 AM, revealed they had been trained to identify a resident by asking the resident his or her full name and by looking at the photo in the MAR. The identifiers on the doors were not used as they get moved around and switched at times. They also were trained to ask another associate if in doubt of a resident's ability to provide accurate identification. Interview with the Director of Nursing (DON), on 01/29/14 at 5:31 PM, revealed LPN #3 had worked since the incident on 11/27/13 but had not passed medications again. She revealed she did believe the incident should have occurred and LPN #3 should have been competent enough to double check the identity Resident #3. Additionally, she stated she felt LPN #3 was ready to pass medications on her own and there was always another associate there if she needed them. Further interview on 01/30/14 at 3:52 PM, revealed nursing staff should take the medication cart to the resident's room to have what was needed to administer medications safely and effectively. She stated it was not acceptable practice to leave the medication cart at the nurses' station and walk the medications to the resident's rooms. Additionally, she stated she did not feel a need to assess the other residents that LPN #3 had administered medications to because she was not aware of any other medication errors. Interview with the Executive Director (ED), on 01/29/14 at 5:15 PM, revealed LPN #3 received in-servicing prior to being allowed to pass any medications and she did not feel like a systems' process was the cause of the incident but rather human error. Additionally, she revealed she did not feel Resident #3 receiving the wrong medication caused any [MEDICATION NAME] harm but could have caused increased anxiety levels. She stated the resident was alert and coherent when she left the faciity on [DATE] after the incident and she was not in fear for the resident's life. Interview with Physician #1, on 01/29/14 at 2:55 PM, revealed the medication Resident #3 received could have been life threatening. She stated she did see the resident in the hospital and did not feel the resident had any significant [MEDICATION NAME] side effects from receiving the wrong medications. Interview with Resident #3, on 01/29/14 at 11:35 AM, revealed he/she thought he/she was going to die after getting the wrong medications. Further interview revealed he/she now request the medications be brought into the room unopened so they may be identified by him/her prior to taking them. **The facility implemented the following actions to remove the Immediate Jeopardy: On 11/27/13, the Director of Nursing (DON) interviewed LPN #3 related to the cause of the medication error and determined LPN #3 required increased training in medication administration prior to administering more medications. LPN #3 received one on one training from the Staff Development Coordinator (SDC) related to Medication Administration, including the five (5) rights of medication administration (right resident, right medication, right time, right dosage and right route) which included a competency exam at the end of the training. LPN #3 had adminstered four other residents (Resident #1, #9, #10 and #11's) medication on 11/27/13. The Administrator reviewed each resident's individual MAR for missed medications an/or discrepancies. The records were reviewed for any changes in condition. All four resident were seen by the physician. On 01/09/14, education on medication administration, to include the five rights of medication administration was conducted by the DON and the SDC during a nurse meeting. To determine the licensed nursing staff had understood the inservice, each nurse had to demonstrate understanding to the DON and take a competency exam. Any nurses who did not attend the 01/09/14 inservice for any reason would have the same training and take the competency exam by 02/02/14. After a new hired nurse completed class room orientation, the SDC, DON, or Assistant DON (ADON) would provide oversight as the new nurse employee performs his/her first medication administration pass to validate the nurse is following correct procedures for medication administration to include the five rights of medication administration correctly and would document this in the nurses file and report to the DON and Executive Director (ED) that the nurse was safe to perform medication administration. Any nurse not following the medication administration procedures would be removed from the patient care area and re-trained by the DON, ADON, or SDC and have oversight provided for the next medication pass. Monitoring and System Change: The DON, ADON, or SDC will complete a medication administration audit of 100% of licensed nurse staff to ensure compliance with medication administration to include the five rights of medication administration. Each nurse (LPN or RN) will be observed for a minimum of five (5) residents during medication administration during their shift. If any nurse does not follow the proper procedures for medication administration, they will be immediately removed from patient care area and re-educated by DON, ADON, or SDC and monitored again during medication administration. The medication administration audit began January 31,2014 at 9 PM and will continue with each nurse's medication administration pass until every nurse has been audited during a medication administration pass. On 02/03/14 the DON, ADON, or SDC began a seven (7) day a week medication administration audit of two (2) nurses for thirty (30) days, then three (3) days a week medication administration audits of two (2) nurses for the next thirty (30) days, then one (1) day a week medication audits of two (2) nurses for the next thirty (30) days. The results of the audits will be reviewed by the PI Committee and if any nurse does not follow the proper procedures for medication administration, the nurse will be removed from the patient care area and re-educated by the DON, ADON, or SDC and have monitoring again of a medication administration pass. Medication audits will validate the care plans are being followed per physician orders. The Medication cart will be taken with each nurse on their routine medication pass. A small pocket/hand size picture album containing a picture of each resident, labeled and in alphabetical order, has been made for each medication cart so the nurse can carry the resident picture album with them for as needed (PRN) medications or other situations in which resident identification is needed, without the need for the medication cart. An inservice related to the use of the photo album was completed on 02/05/14 and included the reason for the album as well as the need to take the medication cart to the resident's room with the Medication Administration Record [REDACTED]. If any nurse missed the inservice, the DON, ADON, or SDC was to meet with each nurse individually to assure training on the new photo album prior to their shift. The DON, ADON, or SDC will monitor two (2) nurses daily for thirty (30) days, two (2) nurses three (3) days a week for the next thirty (30) days and two (2) nurses one (1) day a week for 30 days, to ensure nurses have the MAR binder or the picture album with them for PRN medications or other situations where resident identification is needed. Any nurse not having the MAR binder or the photo album during medication administration will be removed from the patient care area and re-educated by the DON, ADON, or SDC to ensure the importance of having the resident identification available during medication administration. Education related to the photo album will be added to new employee orientation for nursing staff and the monitoring outcomes will be taken to the Performance Improvement (PI) Committee for review. All residents pictures were updated by the Executive Director (ED) and Medical Records Clerk on 02/05/14 and placed in the MARS and Treatment Administration Records (TARS) and photo albums were completed by the ED, DON, ADON, and Activities Director. The pictures are to be reviewed quarterly by medical records staff and/or upon any change in condition that may affect a resident's personal appearance, to ensure the photo in the MAR indicated [REDACTED]. The Administrator is responsible to monitor the process to ensure quarterly and as needed meetings, and report to the PI Committee of the outcomes. Performance Improvement Committee: The Center will add the option of MAR binder or hand/pocket size photo album as an option for resident identification to the medication administration policy. The hand size photo album was made available to nursing staff to assist in resident identification when administering a PRN medication or for any other situation where the medication cart may not be needed at the resident's room. The photo album will be added to the orientation policy given to any new nurse employee. The ED notified the Medical Director of the Immediate Jeopardy on 01/31/14 at 8:15 PM. The Allegation of Compliance (AoC) was reviewed with the Medical Director for approval and any new suggestions on 02/01/14 and on 02/05/14. The PI Committee met on 02/01/14 and on 02/0514 to review the AoC and to validate completion of staff education, photo album in place, resident's photos updated and monitoring of photos in place. The PI Committee consists of the Administrator, DON, ADON, SDC, Minimum Data Set (MDS) nurse, Social Services Director, Activities, Medical Director, Medical Records and other staff as needed. The PI Committee will meet weekly for thirty (30) days to review the medication audits monitoring, resident identification monitoring, medication errors if any and root causes, that all new nursing staff have had all medication administration education including an audit of the first medication administration pass and ensure the employee file reflects the training and validation. The PI Committee will meet two (2) times a month for the next thirty (30) days and then monthly thereafter to monitor the above mentioned and make changes and/or suggestions as needed to stay in compliance. **The State Survey Agency validated the corrective action taken by the facility as follows: Review of an Education Acknowledgment Form, dated 11/27/13, revealed LPN #3 received one on one training from the SDC related to medication administration guidelines including the five (5) rights of medication administration and how to identify the resident appropriately. Review of memos posted, on 11/28/13, at each nursing station revealed staff was to read and sign the memo related to the five (5) rights of medication administration as well as the policy related to resident identification. Review of an in-service provided to the licensed nursing staff, on 01/09/14 at 7:00 AM and 1:30 PM, revealed all licensed staff employed at the facility received training related to pharmacy and medication pass, medicare, behavior, and nursing documentation, incident reports, and fall/skin injury assessment. Staff also demonstrated a medication administration pass and completed a check off list and also completed a pharmacy review quiz. Interview with the ED, on 02/03/14 at 1:15 PM, revealed every nurse in the facility had been trained over the weekend and each nurse had been checked off on a medication administration pass which included medication administered to five (5) residents. Additionally, every nurse was trained on proper resident identification. Interviews with RN #1 and RN #2, on 02/11/14 at 9:25 AM and on 02/10/14 at 1:45 PM respectively, revealed an inservice was conducted on 02/07/14 with nursing staff related to the use of the new photo album to be used in resident identification during a PRN medication pass, blood sugar finger sticks, or for any other reason the medication cart may not be needed at the resident room. Additionally, the in-service was related to identifying the resident by asking his/her full name when entering the room and if the resident was unable to give an appropriate name then another staff member was to be consulted to aide in the proper identification of the resident. Interviews with LPNs #1 and #6, on 02/10/14 at 3:05 PM and 1:50 PM respectively, revealed there was an in-service conducted on Friday, 02/07/14 related to medication administration and proper identification of the resident as well as the five (5) rights to medication administration. Additionally, the purpose of the new photo albums was discussed as well as checking the medication three (3) times prior to administration to assure the five (5) rights were being followed. Interviews with LPNs #2, #7, #9, #5, and #8, on 02/11/14 at 9:00 AM, 12:25 PM, 12:30 PM, 12:40 PM, and 12:42 PM, revealed an in-service was conducted on Friday, 02/07/14 related to medication administration and proper identification of the resident as well as the five (5) rights to medication administration. Additionally, the purpose of the new photo albums was discussed as well as checking the medication three (3) times prior to administration to assure the five (5) rights were being followed and it was re-enforced that if the resident was unable to identify themselves, then another associate should be consulted to aide in the resident's identity. Observation of medication administration passes, on 02/10/14 at 1:50 PM and 3:05 PM, revealed LPN #6 and LPN #1 passing medications following the facility's policy and procedure except for asking the resident his/her full names when entering the room. However, they did call the residents by his/her first names prior to administering medications to them. When asked why they didn't ask the residents their full names, they both explained that they have known these residents for a long time, but if the residents were new to the facility and if there was a question of the resident's identity, then another associate would be asked to assist in identifying the resident. The photo albums were on the medication cart and were being used accordingly. Review of Residents #1, #9, #10 and #11's care plans revealed an intervention to provide medications as ordered. In addition, record reviews revealed the residents were seen by their physicians with no change in conditions identified and there were no identified changes in the residents noted. Interview with the ED and the DON, on 02/11/14 at 2:12 PM, revealed the QA committee is meeting weekly for thirty (30) days to review the medication audit monitoring, the resident identification monitoring, medication errors if any and root causes, that all new nursing staff have had all medication administration education, been audited on first medication administration pass and employee reflects this training and validation. The PI committee will meet two (2) times a month for next thirty (30) days and then monthly thereafter to monitor the above mentioned and make changes or suggestions as needed to stay in compliance.

Based on observation, interview, record review, and review of the facility's policy and procedures, the hospital History and Physical, hospital Discharge Summary and the hospital's January 2014 Medication Administration Record (MAR), it was determined the facility failed to administer medication in accordance with acceptable standards of practice for one (1) of fifteen (15) sampled residents (Resident #15). The facility failed to have an effective system in place to monitor the placement and removal of medication [MEDICATION NAME]es and identify if [MEDICATION NAME]es were in place on admission to ensure the medication was administered at the right dose. On 01/14/14, Resident #15 was readmitted to the facility with a physician's orders [REDACTED]. The hospital had applied the [MEDICATION NAME] that morning prior to transfer to the facility. On 01/17/14, the facility applied a [MEDICATION NAME]; however, there was no documented evidence the facility had identified the hospital [MEDICATION NAME] was in place on admission or that the patch had been removed on or before applying another patch. On 01/18/14 at approximately 6:15 PM, Resident #15 was found staring blankly and with minimal response to verbal stimuli. The physician was notified and a fifty (50) microgram (mcg) [MEDICATION NAME] Patch was removed from the resident's chest at the facility. The resident was sent to the emergency room for evaluation. Review of hospital documentation revealed a [MEDICATION NAME] Patch was removed in the emergency room . The resident was administered a dose of [MEDICATION NAME] (Opiate drug reversal drug) 0.4 milligrams (mg) via IV piggyback and the resident woke up and stated his/her name to the emergency room Nurse. Resident #15 was admitted to the Intensive Care Unit (ICU), on 01/19/14 at 12:03 AM, with a primary [DIAGNOSES REDACTED]. The facility's failure to ensure medication was administered at the right dose according to nursing standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/03/14 and was determined to exist on 01/23/14. The facility was notified of the Immediate Jeopardy on 04/03/14. An acceptable Allegation of Compliance was received on 04/08/14 alleging the removal of the Immediate Jeopardy on 04/08/14. The State Survey Agency validated, on 04/09/14, the Immediate Jeopardy was removed on 04/08/14, as alleged. The Scope and Severity was lowered to a "D" at 42 CF 483.20 Resident Assessment F281 and 42 CF 482.25 Quality of Care F333 while the facility develops and implements the Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Kentucky Board of Nursing Advisory Opinion Statement (AOS) #14 Patient Care Orders, revised 10/2010, revealed Registered Nurses and Licensed Practical Nurses are responsible for the administration of medication or treatment as authorized by a Physician, Physician Assistant, or Advanced Practice Registered Nurse. Components of medication administration include but are not limited to preparing and giving medication in the prescribed dose, route, and frequency. Review of the facility's Disposal of [MEDICATION NAME] Patches policy, last revised 10/2010, revealed the facility should have the disposal of a [MEDICATION NAME] witnessed by another nurse to prevent diversion. Document the removal and disposal of the patch. Record review revealed the facility admitted Resident #15 on 01/14/14 with [DIAGNOSES REDACTED]. Review of Resident #15's hospital January 2014 MAR revealed, on 01/14/14, the resident was administered a fifty (50) mcg [MEDICATION NAME] Patch at 8:32 AM, at the hospital. However, review of the resident's "Initial Data Collection Tool/Nursing Service" form which included a skin assessment, Nurse's Notes, dated 01/14/14, and the facility's January 2014 MAR revealed there was no documented evidence the facility had identified Resident #15 was admitted with a [MEDICATION NAME] Patch in place. Interview with Registered Nurse (RN) #8, on 03/26/14 at 10:22 AM, revealed he was the admission nurse on 01/14/14, when Resident #15 was admitted to the nursing facility. He stated he could not remember whether or not the resident had a [MEDICATION NAME] Patch on admission. Review of Resident #15's admission orders [REDACTED]. Further review of the January 2014 MAR revealed a [MEDICATION NAME] was applied to the resident at the facility on 01/17/14; however, there was no documented evidence a [MEDICATION NAME] Patch was removed on, or before 01/17/14 to ensure an accurate dose of medication was administered. Review of Nurse's Notes, dated 01/18/14 at 5:15 PM, revealed Resident #15 was staring blankly with minimal response to verbal stimuli. The physician was notified and instructions were received to remove the [MEDICATION NAME] Patch and send the resident to the emergency room for evaluation. Review of the Nursing Home to Hospital Transfer Form, dated 01/18/14 at 6:40 PM, revealed a [MEDICATION NAME] Patch was removed prior to sending the resident to the emergency room . Interview with RN #1, on 03/26/14 at 6:10 PM, revealed when she assessed Resident #15, the resident's respirations were shallow and the resident was lethargic. The RN stated she directed Licensed Practical Nurse (LPN) #4 to remove the resident's [MEDICATION NAME] Patch. RN #1 stated to her knowledge the resident had only had one (1) [MEDICATION NAME] Patch . Interview with LPN #4, on 03/26/14 at 6:27 PM, revealed she was in Resident #15's room and was asked by RN #1 to remove a [MEDICATION NAME] Patch from the resident because he/she had become lethargic. She stated she removed the patch from the right side of the chest and did not see any other patches on the resident. Interview with LPN #1, on 03/28/14 at 10:17 AM, revealed she was in Resident #15's room and RN #1 stated the resident was unresponsive and asked LPN #4 to remove a [MEDICATION NAME] Patch. LPN #1 stated the resident was rolled several times in the process of getting him/her ready for discharge and she did not notice another patch on the resident. Review of the Hospital Discharge Summary, dated 01/23/14, revealed Resident #15 was brought to the emergency room for confusion and a [MEDICATION NAME] Patch was found on the resident; the patch was removed at the hospital. The resident was given [MEDICATION NAME] and immediately started to arouse and was able to tell the nurse his/her name. Interview with RN #7, on 04/02/14 at 11:22 AM, revealed he was the Admission Nurse on 01/19/14, when Resident #15 was admitted to the Intensive Care Unit from the emergency room . He stated his documentation from 01/19/14 indicated he had been informed the resident had a [MEDICATION NAME] Patch removed in the emergency room . Interview with the Hospital Pharmacist Manager, on 04/02/14 at 11:10 AM, revealed if a [MEDICATION NAME] Patch was left in place and another applied the resident would not be at a full dose but would be receiving between fifty (50) and one hundred (100) mcg related to [MEDICATION NAME] being a residual drug. Interview with Director of Nursing (DON), on 03/28/14 at 3:00 PM, revealed nursing staff perform a head to toe assessment on new admissions and she would expect the nursing staff to know if a resident had a patch on and would expect them to document it in the nursing notes or on the MAR. Interview with the facility's Medical Director, on 03/28/14 at 3:15 PM, revealed he would have expected nursing staff to look at all of the resident's medications and if the list included a [MEDICATION NAME] Patch, he would have expected the nurse to assess the resident to see if the patch was administered in the hospital prior to coming to the nursing home. Additionally, he stated he could not say whether or not the dose of [MEDICATION NAME] the resident had was life threatening as he did not assess her. **The facility implemented the following actions to remove the Immediate Jeopardy: On 03/15/14, Resident #15 was discharged home with family and no longer resides at the center. The facility initiated an internal investigation at the time the resident was readmitted on [DATE] and was identified as having an accidental narcotic overdose. The DON, ADON, SDC, and Regional Director of Clinical Services (RDCS) conducted a medication pass audit which included administration, rotation, and patch presence on 02/01/14 and 02/06/14. No discrepancies were identified and the audits were on-going. On 04/07/14, the DON and RDCS completed a validation to ensure that all nine (9) residents with any type of [MEDICATION NAME] had the location of the patch on the resident documented on the MAR and that all medications were being administered per physician's orders [REDACTED]. On 01/24/14, two (2) additional residents were identified as receiving [MEDICATION NAME]es to treat pain. The DON verified the physician's orders [REDACTED]. [MEDICATION NAME]es were audited by the DON on 01/24/14 for all residents with orders to verify the patch count was accurately reflective of the narcotic count sheet. On 04/03/14, the RDCS and the DON reviewed the documentation of the residents with [MEDICATION NAME]es (two residents from 01/23-02/06/14, two (2) residents from 02/06-02/07/14, three (3) residents from 02/07/14-present). The [MEDICATION NAME] orders and January to present MARs reflected the resident's patches were applied per physician's orders [REDACTED]. Residents who had an order for [REDACTED]. The Pharmacist conducted a review of all current [MEDICATION NAME] orders and counts were correct on 02/04/14. She also reviewed the documentation of the location of the patch on the MARs and verified each shift placement check. On 01/31-02/02/14, all licensed nurses were provided education on medication administration including [MEDICATION NAME]es. This education was completed by the DON and the Staff Development Coordinator (SDC) and was provided for 100% of the licensed nurses before midnight on 02/02/14. On 04/03/14, the RDCS completed education for the DON, Assistant Director of Nursing (ADON), SDC, and the Minimum Data Set Coordinator (MDSC) which included: ? [MEDICATION NAME] administration/removal policy and procedure ? Required documentation of the [MEDICATION NAME] removal and application, including anatomical location of patch to be on the MAR. ? Admission documentation in admission assessment/notes to include [MEDICATION NAME]es present and the location. ? Notification of DON or ADON upon receipt of new [MEDICATION NAME] orders received. All licensed nurses received the above training beginning on 04/03/14. Education was completed by the DON, ADON, or MDS nurse. Education included a quiz which required a score of 100% to validate competency. This education was completed with 100% of licensed staff on 04/04/14. Any licensed nurse who did not receive the above training would not be allowed to work until the training was completed. The DON, ADON, MDS Nurse, and SDC provided education to the Certified Nursing Assistants (CNAs) to include observing for [MEDICATION NAME]es during activity of daily living (ADL) care and to notify the Charge Nurse if more than one (1) patch was identified on the resident. Education was initiated on 04/04/14 and was completed prior to midnight to all staff on duty. Any staff who did not receive the training prior to midnight on 04/04/14 was to receive the training prior to beginning his/her next working shift. Nursing will notify the DON or ADON at the time of all new [MEDICATION NAME] orders received. On 04/03/14 the DON and ADON completed audits of residents' records who were receiving a [MEDICATION NAME] for documentation of placement on the MAR and verified the patch was located on the resident in accordance to the assessed, documented site. The DON,ADON, and RCDS reviewed resident records who currently had [MEDICATION NAME]es to validate the physician's orders [REDACTED]. Beginning 04/04/14, the DON, ADON, SDC, Unit Manager, MDS Nurse and/or RDCS will validate the [MEDICATION NAME]es orders are correct, recorded on the MAR, location will be documented on the MAR, and verify the patch is located on the resident in accordance with the assessed, documented site. The process was to occur seven (7) days a week for thirty (30) days, then would be completed four (4) times a week for thirty (30) days. If a discrepancy was identified, the nurses involved would not be allowed to administer medications until they were retrained and deemed to be competent in medication administration. The DON, ADON, SDC, or Unit Manager will monitor the next five (5) admissions with a [MEDICATION NAME] order beginning on 04/05/14, and again on 04/07/14 to ensure [MEDICATION NAME] orders were recorded on the MAR correctly, the location was documented on the MAR and on the initial data collection tool. They will verify the patch was on the resident as the MAR indicated. If a discrepancy was identified, the nurses involved would not be allowed to administer medications until they were retrained and deemed to be competent in medication administration. All audit and monitoring outcomes would be presented to and reviewed by the Performance Improvement (PI) Committee for revision or plan recommendations. Audits would be completed seven (7) days a week, for the next thirty (30) days, then at a rate of four (4) times per week for thirty (30) days. The PI Committee would meet weekly over the next thirty (30) days, then bi-weekly for thirty (30) days to review results. PI meetings were held on 02/05, 02/06, 02/12, 02/19, 02/26, 03/05, 03/07, 03/09, and 03/19/14. Review of education provided in regard to medication administration as well as full review of completed medication administration audits were conducted at each PI meeting. On 04/03/14, the Medical Director and the resident's attending physician were notified of Immediate Jeopardy and the facility's action plan and both agreed with the action plan. The PI Committee met on 04/04/14 to review the action plan, validate education as completed, and to update the Medical Director on the additional documentation for new admissions on the initial data collection tool and to validate monitoring was in place. The PI Committee consists of the Executive Director, DON, ADON, SDC, MDS Nurse, Social Services, and Activity Director. The PI Committee was to meet weekly for thirty (30) days to review all audits, new admissions with [MEDICATION NAME]es, and revise the care plans to ensure resident's individual needs were met and residents were receiving care to meet the highest practicable well being. The PI Committee was to meet two (2) times a month for thirty (30) days, then monthly to review all audit findings and make revisions as needed to the action plan based on audit findings. **The State Survey Agency validated the corrective action taken by the facility as follows: Record review revealed Resident #15 was discharged home with family on 03/15/14. Review of Medication Pass Audits, dated 02/01/14 and 02/06/14 revealed the DON, ADON, SDC, and RDCS conducted a medication pass audit and monitored the entire medication pass including the administration of medication patches to include ensuring the rotation of sites for the patches, patches were dated and timed, as well as documented on the MAR for placement and removal of the old patch. Random patch audits were ongoing and continued to be performed three (3) times a week. Review of the MAR audit list, dated 04/07/14, revealed the DON and RCDS completed observations of the nine (9) residents with any type of [MEDICATION NAME] to ensure the patch was located at the same site as was documented on the MAR. In addition, they reviewed the physician's orders [REDACTED]. Review of the Physician's Progress Notes, dated 04/03/14, for Resident #10 and Resident #3 revealed both residents were assessed and received [MEDICATION NAME]es with no adverse side effects noted. Review of a Medication Audit form, dated 04/04/14, revealed the pharmacists reviewed the MARs for Resident #3 and Resident #10 for correct documentation for placement, checks, application, removal, and disposal of [MEDICATION NAME]es with no concerns noted. Review of the inservice log, dated 01/31/14-02/02/14, revealed 100% of licensed staff was inserviced and a post test was completed to verify competency of [MEDICATION NAME] administration by the DON and SDC. Review of training, dated 04/03/14, revealed 100% of licensed staff was inserviced on the procedure for Admission/Readmission of residents utilizing [MEDICATION NAME]es by the DON, ADON, SDC, and MDS Coordinator. The training included [MEDICATION NAME] administration and removal policy and procedure; the required documentation of patch removal and application, including location of the patch; the documentation on Admission Assessments and Notes should include if any patches present and the location of the patches; and Notification of the DON and/or ADON upon receipt of new patch orders. A competency exam was given to verify the understanding of the training. 100% of licensed staff was inserviced and new hires will receive the same training. Review of the CNA training log, dated 04/04/14, revealed a phone training was completed by the Regional Nurse Consultant on 04/04/14 which included to observe for patches during care and to utilize a "stop and watch" tool to report areas to the charge nurse. Interviews with RN #2, RN #4, RN #10, RN #11, LPN #1, LPN #5, LPN #6, LPN #7, LPN #8, and LPN #10, on 04/09/14 between 10:15 AM and 10:45 AM, revealed they were trained on the disposal process for [MEDICATION NAME]es, documentation of the site of the patch on the resident, physician notification if more than one (1) patch was found on a resident, and the process of documenting patches on new admissions. Additionally, RN #2, RN #4, RN#10 and RN #11 were educated on the notification of the Director of Nursing and/or the Assistant Director of Nursing of new orders for [MEDICATION NAME]es, the admission process for [MEDICATION NAME]es documentation, placement checking of the patch and to complete a complete body audit if the patch was not where it was supposed to be and conduct an investigation, and the disposal process for the patches which includes two (2) licensed nursing staff to witness and destroy the patch by folding it and placing it in a Sharps container. Interviews with CNA #1, CNA #2, CNA #3, and CNA #4, on 04/09/14 between 10:15 AM and 10:45 AM, revealed they were inserviced on reporting to the Charge Nurse if while performing care to a resident, two (2) patches were found to be present on the resident. They stated they would fill out a "Stop and Watch" form and turn it in to the Charge Nurse. Review of the [MEDICATION NAME] Patch Audits, on 04/08/14 and 04/09/14 revealed all new [MEDICATION NAME] orders were reported to the DON and/or ADON. The DON and ADON completed audits of residents who were currently on a [MEDICATION NAME] of any kind with the last audit completed on 04/08/14 and to continue every day for seven (7) days. The facility did not have any new admissions on [MEDICATION NAME]es at this time. On 04/03/14, the Medical Director was notified of the AoC and agreed with the plan with a verified signature. Review of the Quality Assurance meeting notes, dated 01/01/14, revealed the AoC was discussed via a phone call between the Medical Director and the Executive Director. Review of the PI Committee meeting documentation, dated 01/01/14 through 03/19/14 revealed meetings were held weekly to review all audits, new admissions with [MEDICATION NAME]es, and revise the care plans to ensure resident's individual needs were met and residents were receiving care to meet the highest practicable well being. Interviews conducted with the ADON, DON, and the Executive Director, on 04/09/14, revealed medication administration was discussed in the PI meetings as stated in the AoC and training was provided to licensed nursing staff as well as the CNAs related to identifying multiple patches on residents or a patch on a resident on initial admission to the facility.